What Is Cheilitis? – Symptoms, Causes, Treatment

What Is Cheilitis?/Cheilitis is an inflammation of the lips, which could be acute or chronic. The inflammation primarily arises in the vermilion zone but may extend to surrounding skin and less commonly, to the oral mucosa. It may be caused by a multitude of factors, including contact irritants or allergens, chronic sun exposure, and nutritional deficiencies, as well as by various cutaneous and systemic illnesses.

Cheilitis is inflammation of the lips. This inflammation may include the perioral skin (the skin around the mouth), the vermilion border, or the labial mucosa. The skin and the vermilion border are more commonly involved, as the mucosa is less affected by inflammatory and allergic reactions.[rx]

Types of Cheilitis

It is a general term, and there are many recognized types and different causes. Cheilitis can be either acute or chronic. Most cheilitis is caused by exogenous factors such as dryness (chapping) and acute sun exposure.[rx] Patch testing may identify allergens that cause cheilitis.[rx]

The lips can be inflamed because of an infection or skin condition

  • Herpes simplex
  • Angular cheilitis
  • Granulomatous cheilitis
  • Orofacial granulomatosis
  • Crohn skin disease
  • Actinic cheilitis
  • Exfoliative cheilitis
  • Glandular cheilitis
  • Lichenoid cheilitis
  • Cutaneous lupus erythematosus

They may be inflamed because of an allergytoxin, medication or injury.

  • Eczematous cheilitis
  • Allergic contact cheilitis
  • Pigmented contact cheilitis
  • Cheilitis in musicians
  • Contact reactions to lipsticks and other lip care products
  • Irritant contact dermatitis
  • Allergic contact dermatitis
  • Smoking and its effects on the skin
  • Sunburn
  • Isotretinoin treatment
  • Acitretin treatment
  • Denture stomatitis

Eczematous cheilitis most common form of cheilitis and is more prevalent in people with a history of allergies. 

  • Angular cheilitis/infective cheilitis – may present at any age with an equal male to female ratio but is especially likely in older individuals wearing dentures. Children suffering from these forms have a history of recurrent infections or immune defects.
  • Actinic cheilitis – is more prevalent in geographic areas with high ultraviolet (UV) irradiation, and in fair-skinned men who work outdoors (e.g., fishermen, farmers) in their fourth to the eighth decade of life. Certain genetic conditions associated with increased susceptibility to solar damage may predispose individuals to acquire actinic cheilitis at an early age (e.g., xeroderma pigmentosum, oculocutaneous albinism).
  • Glandular cheilitis – is a rare form of cheilitis, more prevalent in older males, but individuals in younger age and women also may be affected. The cause is unknown, but several factors have been identified, including atopy, infection, chronic exposure to the sun, repeated licking, and use of tobacco.
  • Cheilitis granulomatosis –  is rare. It primarily affects young adults but can occur at any age, with equal ration in male to female. It is idiopathic. However, there are several predisposing factors, including food allergy, genetics, infection, and atopy.

Causes of Cheilitis

  • Eczematous cheilitis –  could be a result of exogenous factors (irritant contact cheilitis, allergic cheilitis) or endogenous factors (atopic cheilitis).
  • Dry, chapped lips – Frequent exposure to hot or dry winds can cause loss of plasticity of keratin in vermillion, leading to sores and dry, scaly lips. The patient might get into the habit of chronic licking of lips to pick upscales, which further aggravates the problem. It is also referred to as irritant contact cheilitis.
  • Allergic Contact Cheilitis – A delayed-type hypersensitivity reaction to allergens that come in contact with the lips can cause inflammation of the lips. It is also known as lipstick cheilitis since several ingredients found in lipsticks may act as irritants. The most common cosmetic sensitizers identified by patch testing include fragrances, Myroxylon pereirae, and nickel. However, some ingredients unique to lipsticks may also cause lip dermatitis. For example, castor oil, colophony, shellac, azo dyes, sesame oil, preservatives, ozonated olive oil, propolis, and copolymers. Apart from lipsticks, allergic contact cheilitis can be caused by a variety of other substances that come into contact with lips. They could be found in mouthwashes, toothpaste, and even food. Lipstick cheilitis may present as persistent irritation and scaling, sometimes associated with edema and vascularization, confined to vermillion or extending beyond in some cases. Cheilitis caused by food may involve the skin around the mouth.
  • Atopic Cheilitis – Patients with a history of atopy or atopic dermatitis commonly have associated atopic cheilitis. It presents with dryness, erythema, scaling, and fissuring of lips.
  • Angular Cheilitis – Angular cheilitis, also known as angular stomatitis or perlèche, is an acute or chronic inflammation of the skin and adjacent labial mucosa at the angles of the mouth. It manifests as a roughly triangular area of erythema and edema at one, or more frequently both, angles of the mouth. The most common cause of angular cheilitis in adults is a fungal infection, Candida albicans, and less commonly, Staphylococcus aureus. Poor oral hygiene, ill-fitting dentures, or absence of teeth as in the elderly can lead to excessive moisture and maceration from saliva leading to these infections. Less commonly, the nutritional deficiencies, particularly those of riboflavin (B2), niacin (B3), pyridoxine (B6), folate (B9), iron, and general protein malnutrition, may produce smooth, shiny, red lips associated with angular stomatitis, collectively known as cheilosis. 
  • Infective cheilitis – Viral cheilitis: It is mainly due to the herpes simplex virus, especially type 1. The primary herpes infection (herpetic gingivostomatitis) combines post-vesicular erosive and crusted cheilitis with diffuse stomatitis leading to dysphagia, perioral vesicles, fever, and cervical lymphadenopathy. Recurrence of oral herpes affects the lips in most cases. It manifests as a cluster of blisters accompanied by a burning sensation. Next, the vesicles erode to leave behind crusted erosions that resolve in a week.
  • Bacterial Cheilitis – The most common cause of bacterial cheilitis is infection with group A Streptococcus or Staphylococcus.
  • Mycotic cheilitis  Cheilitis caused by candida manifests with erythema and painful edema of the lips, sometimes with fissures, and it is usually accompanied by acute (pseudomembranous candidiasis) or chronic stomatitis, and/or angular cheilitis. The diagnosis is confirmed by taking a specimen for mycological examination.
  • Parasitic cheilitis Leishmaniasis is a possible cause of cheilitis in endemic regions. It gives the appearance of an erythematous papule or plaque that gradually enlarges and then ulcerates or a permanent lip enlargement (macrocheilia).
  • Actinic Cheilitis – Actinic Cheilitis (also known as solar keratosis of the lip or actinic keratosis) originates from the proliferation of atypical epidermal keratinocytes due to chronic sun exposure. It is a premalignant condition and occasionally progresses to squamous cell carcinoma. Most cases are observed in outdoor workers, fair-skinned individuals, and during the fourth to eighth decades of life. The lower lip border receives the highest ultraviolet radiation, being at the right angle to the midday sun rays and poorly protected by melanocytes. Clinical symptoms are varied, depending upon the stage of the disease, and may include erythema, edema, plaques, and nodules and later develop into ulceration as the lesion becomes malignant. Notably, the lesions have a characteristic “sandpapery” feel to touch.
  • Drug-induced cheilitis – Systemic retinoids such as etretinate and isotretinoin cause dryness, erythema, scaling, and cracking of the lips (may include angles of the mouth) in almost all the patients. Less frequently, it may also be caused by any other drugs that cause dryness of mouth and lip.
  • Glandular cheilitis – It is a rare, chronic inflammation with tumefaction and sometimes suppuration of salivary glands at the lower lip. The most common clinical form is the simple cheilitis glandularis, which manifests as a moderate thickening of the lower lip with inflammatory dilated gland duct orifices, from which mucous saliva can be squeezed easily. Older males are most commonly affected, but can also be seen in young individuals and women. In the more severe suppurative form (Volkmann’s cheilitis), the lip is enlarged considerably and persistently (macrocheilia) and is associated with pain and tenderness. Crusts and scales cover the surface, beneath which the salivary duct openings may be found. Eventually, it results in a deep-seated infection that may cause the formation of abscess and fistulous tracts.
  • Cheilitis granulomatosis – Cheilitis granulomatosis is a persistent, idiopathic, nontender granulomatous inflammation of one or both lips. The initial manifestation is sudden diffuse or nodular swellings involving the upper lip, the lower lip, and one or both cheeks in decreasing incidence. Early attacks cause edema of lips that usually subsides in days to hours; however, recurrent attacks may lead to a persistent increase in swelling, leading to firm, rubber-like consistency of lips. Cheilitis granulomatosis can be isolated, idiopathic (Miescher cheilitis granulomatosis), or associated with various systemic conditions (sarcoidosis, Crohn’s disease, tuberculosis). The complete form of Melkersson Rosenthal syndrome combines cheilitis granulomatosis, peripheral facial paralysis, and a fissured tongue with loss of taste sensation.
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Listed below are some of the known causes of actinic cheilitis and risk factors for the condition

  • Chronic sun exposure – The more often the lips are exposed to sunlight, the more likely damage is to occur.
  • Severe sunburn – Sunburn further damages skin cells and causes them to divide and regenerate, increasing the chances of cellular mutations.
  • Sex – Three times more men than women develop actinic cheilitis.
  • Fair skin – A majority of those with actinic cheilitis are white or fair-skinned. Rates are very high in people with albinism or those with skin pigment disorders.
  • Tropical, subtropical, or desert environments – Regions near the equator have increased ultraviolet exposure. Tropical and desert regions also typically have more sunny, warm days that encourage being outdoors.
  • Jobs that involve being outdoors – Jobs or hobbies that require being outdoors in the sun for more time increase the risk of sun damage. Lifeguards, construction workers, hikers, marathon runners, farmers, and sailors may have a higher chance of developing actinic cheilitis.
  • Age – Usually the result of chronic or long-term sun damage, the condition mostly impacts adults.
  • Smoking – Smoking or chewing tobacco can weaken lip epithelium and make it more vulnerable to sun damage.
  • Actinic prurigo – This rare, itchy photosensitivity condition causes the skin to be more sensitive to sun damage.
  • Excessive alcohol use.
  • Oncogenic human papillomavirus – the virus that causes warts.
  • Immune disorders or immunosuppressing medications – Medications that weaken and suppress the immune system usually increase the risk of sun damage.
  • Everted lower lip – When the lip is turned more outward instead of inward.
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Symptoms of Cheilitis

The main things you’ll notice are irritation and soreness in the corner(s) of your mouth. One or both corners may be:

  • Bleeding
  • Blistered
  • Cracked
  • Crusty
  • Itchy
  • Painful
  • Red
  • Scaly
  • Swollen

Your lips can feel dry and uncomfortable. Sometimes your lips and mouth can feel like they’re burning. You also might have a bad taste in your mouth.

Other symptoms include:

  • bad taste in your mouth
  • burning feeling on your lips or mouth
  • lips feeling dry or chapped
  • difficulty eating as a result of the irritation

Diagnosis of Cheilitis

History and Physical Exam

  • Your physician would take you through a number of questions which might include the history of the onset of the problem, and any underlying or associated complaints or symptoms. The history would include questions about denture history, oral care, other chronic skin conditions, medicine or drug history, the habit of smoking, nutrition and diet, bowel movements, and acid reflux

Evaluation

The diagnosis of most cheilitis is based on clinical signs and a careful anamnesis.

  • The diagnosis of allergic contact cheilitis – is confirmed by a history of allergy and a relevant patch test reaction. Patients with negative patch testing are diagnosed with irritant contact cheilitis or atopic cheilitis.
  • A biopsy is required in cheilitis granulomatosa to confirm the diagnosis. Once the diagnosis of granulomatous cheilitis is made, a thorough etiological assessment is necessary.
  • A biopsy – is also important in chronic actinic cheilitis if there is suspicion of malignant transformation.
    Finally, in the case of allergic cheilitis, an allergy survey is required. It includes a careful history and appropriate allergy tests.
  • Physical Examination – A thorough examination by your physician will help narrow the diagnosis.
  • Lab Investigations – Oral swabs and biopsies help to rule the underlying cause of the disease and confirm the diagnosis. Oral swabs, also known as culture swabs, are done to rule out the infection from candida, staphylococcus bacteria or herpes simplex. A biopsy can help to diagnose a condition a lichen planus or a precancerous lesion.

Treatment of Cheilitis

The therapeutic management of cheilitis is symptomatic and etiological

The goal is to clear out the infection and keep the area dry so your skin isn’t infected again. Your doctor will recommend an antifungal cream to treat fungal infections. Some are:

  • nystatin (Mycostatin)
  • ketoconazole (Extina)
  • clotrimazole (Lotrimin)
  • miconazole (Lotrimin AF, Micatin, Monistat Derm)

If your infection is bacterial, your doctor will prescribe an antibacterial medication, such as:

  • mupirocin (Bactroban)
  • fusidic acid (Fucidin, Fucithalmic)

For someone with uncontrolled diabetes, treatment might include diet and lifestyle changes, insulin therapy, or diabetes medications. Vitamin supplements or changes in diet can help people who develop angular cheilitis due to poor nutrition.

Antibiotics

When the area is infected, then the underlying infection requires treatment. It is important to diagnose the cause of the infection since yeast infections, for example, will not respond to antibiotics. In most cases, a doctor can tell by looking at it whether the infection is bacterial or due to yeast.

Hygiene

Keeping the area clean and dry can ease pain and prevent an infection from worsening. A lip balm or protectant can relieve dryness and protect the skin from saliva. A doctor may also recommend a topical steroid cream, which can be applied to the skin to stimulate healing. A steroid cream may also help with pain and itching.

Fillers and injections

When an issue with the lip or mouth shape makes angular cheilitis more likely, or if a person has had several infections with angular cheilitis, a doctor might recommend treatment to change the shape of the mouth.

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Dry, chapped lips – Avoidance of lip sucking, lip balms, or any other causative agent, and the local application of petroleum jelly is helpful.

Allergic contact cheilitis and atopic cheilitis – Excluding the allergen responsible and applying a low to medium intensity topical steroid and emollients. Sometimes a potent steroid (fludrocortisone) or off-label use of topical calcineurin inhibitors may be required.

Angular cheilitis – The treatment is maintaining oral hygiene, using dentures with the proper fit, using barrier creams (eg, zinc oxide paste) or petrolatum and treatment of sicca symptoms. Vitamin supplements could be given in case of nutritional deficiency. In case of cheilitis due to dentures, dentures must be removed before going to bed at night, brushed intensely, and then soaked in a solution of chlorhexidine gluconate or a dilute solution of bleach (10 drops of solution in a denture cup filled with water).

Infective cheilitis – Maintaining proper oral hygiene, and treatment of the underlying cause of infection is indicated. The most common infection is by Candida albicans which has different treatment approaches depending upon the associated HIV AIDS infection. Topical therapy with clotrimazole troches, miconazole mucoadhesive tablets, or nystatin swish and swallow is recommended as initial therapy in HIV seronegative patients and in HIV seropositive patients with mild thrush. Patients with recurrent infection, moderate to severe illness, or immunosuppression (CD4 <100 cells/microL) should be treated with systemic fluconazole ( an initial 200 mg loading dose, followed by 100 to 200 mg daily for up to 14 after clinical improvement).

Actinic cheilitis – A variety of treatments are used for the management of actinic cheilitis depending upon its severity. Simple observation with regular visits or treatment with liquid nitrogen is advised in case of focal mild or moderate actinic cheilitis. Patients with multifocal or diffuse symptoms may benefit from first-line therapy with topical medications (eg, topical fluorouracil, imiquimod). 5% fluorouracil cream is applied locally twice a day for two to four weeks. Discomfort associated with fluorouracil may lead to poor compliance and patient may be switched to imiquimod 5% cream ( three times per week for four to six weeks). Some may also require photodynamic or laser therapy. Patients with severe diffuse actinic cheilitis without evidence of high-grade dysplasia or cancer on biopsy should be treated with laser ablation with carbon dioxide (CO2) laser or erbium:yttrium-aluminum-garnet (Er: YAG). Surgical excision (vermilionectomy) ensures the histopathologic examination of the entire vermilion and is the treatment of choice for actinic cheilitis with high-grade dysplasia on biopsy.

Drug-induced cheilitis – Lip moisturizers, emollients, and cessation of offending drugs lead to complete resolution of symptoms.

Glandular cheilitis and cheilitis granulomatosis – Various therapies have been implicated for glandular cheilitis, including systemic antibiotics and corticosteroids (topical, intralesional, or systemic), and vermilionectomy (in case of severe symptoms).

Surgery

In severe cases, the affected tissues may need to be removed. Advanced options include:

  • laser ablation, where a laser removes the outer layers of sun-damaged skin
  • cryotherapy, where the affected patches of skin are frozen off
  • vermilionectomy, where the outer layer of the lip is surgically removed
  • electrocautery, where an electrical current is used to remove the abnormal patch

Cosmetic fillers, which are applied by injection, can help with droopy lips that cause angular cheilitis. It is also necessary to ensure that dentures fit properly.

Prevention

Avoiding excessive or long-term unprotected sun exposure is the best way to prevent actinic cheilitis.

Sun protection tips for the lips include

  • applying sunscreen to the body and face daily, even if not spending a long time outside
  • applying lip balms or moisturizers that contain sunscreen, frequently throughout the day, especially when in the sun
  • wearing a wide-brimmed hat and light, long-sleeved clothing in the sun
  • growing a beard or mustache in the case of men

Other ways to reduce the risk of developing actinic cheilitis include

  • stopping smoking or chewing tobacco
  • avoiding excessive alcohol use
  • avoiding tanning beds
  • avoiding creams, facial washes, and medications that thin the skin
  • using extra caution in the sun when on immunosuppressing or anti-inflammatory medications
  • treating cases of oncogenic human papillomavirus or the wart virus properly
  • keeping hydrated, especially when in the sun

References