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Lugovic Mihic 2017-109 NOVO.Indd Acta Clin Croat 2018; 57:342-351 Review doi: 10.20471/acc.2018.57.02.16 DIFFERENTIAL DIAGNOSIS OF CHEILITIS – HOW TO CLASSIFY CHEILITIS? Liborija Lugović-Mihić1,2, Kristina Pilipović2, Iva Crnarić1, Mirna Šitum1,2 and Tomislav Duvančić1 1Department of Dermatovenereology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia; 2School of Dental Medicine, University of Zagreb, Zagreb, Croatia SUMMARY – Although cheilitis as a term describing lip infl ammation has been identifi ed and recognized for a long time, until now there have been no clear recommendations for its work-up and classifi cation. Th e disease may appear as an isolated condition or as part of certain systemic diseases/ conditions (such as anemia due to vitamin B12 or iron defi ciency) or local infections (e.g., herpes and oral candidiasis). Cheilitis can also be a symptom of a contact reaction to an irritant or allergen, or may be provoked by sun exposure (actinic cheilitis) or drug intake, especially retinoids. Generally, the forms most commonly reported in the literature are angular, contact (allergic and irritant), actinic, glandular, granulomatous, exfoliative and plasma cell cheilitis. However, variable nomenclature is used and sub- types are grouped and named diff erently. According to our experience and clinical practice, we suggest classifi cation based on primary diff erences in the duration and etiology of individual groups of cheili- tis, as follows: 1) mainly reversible (simplex, angular/infective, contact/eczematous, exfoliative, drug- related); 2) mainly irreversible (actinic, granulomatous, glandular, plasma cell); and 3) cheilitis con- nected to dermatoses and systemic diseases (lupus, lichen planus, pemphigus/pemphigoid group, angioedema, xerostomia, etc.). Key words: Cheilitis; Infl ammation; Lip Diseases; Actinic Cheilitis; Classifi cation; Dermatitis, Contact Introduction lated to the eff ects of irritants (climatic, mechanical, caustic agents) or allergens (allergic contact cheilitis)5. Th e term ch eilitis indicates infl ammation of the lip and includes many types, i.e. angular, contact, exfolia- Some types of cheilitis last longer and are persistent, tive, actinic, glandular, granulomatous, plasma cell such as chronic actinic cheilitis, granulomatous cheilitis, simplex, etc.1-5. In practice, it is diffi cult to de- cheilitis and plasma cell cheilitis. Furthermore, cheili- fi ne readily the precise type of cheilitis, thus proper tis can also be seen in various skin or systemic diseases diagnostic procedures are necessary to determine the such as lupus erythematosus, lichen planus, atopic exact disease based on its characteristics5. For example, dermatitis, etc. angular cheilitis can occur spontaneously or may be Cheilitis may also be associated with numerous related to several precipitating factors (e.g., systemic conditions or diseases, e.g., nutritional defi ciencies, immune suppression, local irritation and moisture, such as megaloblastic anemia due to vitamin B12 defi - fungal/bacterial infection). Contact cheilitis can be re- ciency, anemia due to iron defi ciency, oral candidiasis, diabetes2,4-8. Correspondence to: Prof. Liborija Lugović-Mihić, MD, PhD, De- Additionally, cheilitis is often divided into particu- partment of Dermatovenereology, Sestre milosrdnice University lar subtypes with no clear classifi cation having yet Hospital Center, Vinogradska c. 29, HR-10000 Zagreb, Croatia E-mail: [email protected] been adopted. Considering its duration, some authors Received August 28, 2017, accepted December 12, 2017 refer to acute or chronic cheilitis, whereby there are no 342 Acta Clin Croat, Vol. 57, No. 2, 2018 Liborija Lugović-Mihić et al. Diff erential diagnosis of cheilitis Table 1. Proposed classifi cation of cheilitis In association with dermatoses and systemic Mostly reversible Mostly persistent diseases (common diseases) Cheilitis simplex Actinic cheilitis Lupus erythematosus Angular/infective cheilitis Granulomatous cheilitis Lichen planus Contact/eczematous cheilitis Glandular cheilitis Angioedema Exfoliative cheilitis Plasma cell cheilitis Pemphigoid/pemphigus Drug related cheilitis Xerostomia Erythema multiforme Crohn’s disease Sarcoidosis, etc. Table 2. Prominent features of mostly reversible cheilitis Mostly reversible Occurrence Related factors Th erapy cheilitis Cheilitis simplex Common Lip licking Advice on environmental conditions Cold, windy, dry weather Application of lip balms, petroleum jelly, emollients, topical corticosteroids, ointments Angular/infective Common Infective agents Elimination of local predisposing cheilitis Immune defi ciency (diabetes, HIV) factors Mechanical factors Topical antimycotics, antiseptics, Nutritional defi ciencies antibiotics, topical corticosteroids (ribofl avin, folate, iron, etc) Contact/eczematous Very common Atopy, contact allergens/irritants Topical corticosteroids (low to cheilitis medium potency), emollients Exfoliative cheilitis Rare Lip licking/picking Corticosteroids Psychological distress Psychotherapy Nutritional defi ciencies (some cases resolve spontaneously) Drug related cheilitis Rare Drugs Emollients Drug elimination if possible clear criteria2. Although there are many recent papers Reversible Cheilitis on cheilitis, they are mostly case reports and overviews of therapeutic or diagnostic procedures based on per- We specify reversible cheilitis (transitory cheilitis sonal experiences and results without specifi c criteria of temporary duration) as a distinct category, which for classifi cation. Since clear classifi cation has not yet includes several subtypes (Table 2). been established, there are no defi nitive recommenda- Cheilitis simplex (chapped lips, common cheilitis, tions for diagnosing all diff erent types of cheilitis. cheilitis sicca) is one of the most common subtypes, Apart from that, cheilitis is also a disease that requires presenting as cracked lips, fi ssures or desquamation of a multidisciplinary approach, which additionally the lips, usually of the lower lip (Fig. 1)2,7. Here fre- complicates adoption of a classifi cation system. We quent lip licking promotes dryness and irritation, end- would like to put forth a classifi cation of cheilitis into ing in separation of the mucosa and cracking. Some three main groups with further particular subtypes authors use a diff erent label for a similarly categorized (Table 1). subtype, lip licking cheilitis, due to lip licking habit or Acta Clin Croat, Vol. 57, No. 2, 2018 343 Liborija Lugović-Mihić et al. Diff erential diagnosis of cheilitis Fig. 1. Cheilitis simplex. Fig. 2. Contact/eczematous cheilitis. frequent lip retraction into the oral cavity (especially in tain drug therapy (e.g., isotretinoin), and somewhat children with atopic dermatitis)6,7. Such licking re- less frequently in primary hypervitaminosis A. It is moves the thin, oily surface fi lm that protects the lips more common during winter when additional lip lick- from moisture loss, leading to lip cracking. Lip lesions ing worsens the condition, and in elderly persons2,5. It are also infl uenced by saliva, the digestive enzymes of can occur in patients with infl ammatory bowel dis- which can irritate the lips by extracting moisture and eases such as Crohn’s disease and ulcerative colitis10. causing evaporation. Some children have the habit of Th is subtype sometimes develops as part of a group sucking and biting the lower lip, whereby a sharply of symptoms, which can include atrophic glossitis, bordered perioral erythema may occur. esophageal webs or strictures, and microcytic hypo- Diff erential diagnosis includes contact cheilitis, chromic anemia (Plummer-Vinson syndrome)11. Con- atopic cheilitis, actinic cheilitis, etc.2,4. Th erapy mostly currence of bacterial or candidal infection (primary or involves advice on dealing with environmental condi- secondary) is common2. Children, especially those tions and the application of lip balms, petroleum jelly, with atopic dermatitis, are most commonly aff ected by emollients and sometimes topical corticosteroids, secondary bacterial infections (staphylococcal and be- mostly low potency ointments. ta-hemolytic streptococcal) on damaged lip corners. Angular cheilitis (also termed perleche, cheilosis, or Angular cheilitis with secondary infections often oc- angular stomatitis or angulus infectiosus) typically curs also in patients with macroglossia (congenital hy- manifests at the corners of the mouth/lips. Th e disease pothyroidism and Down syndrome). is most common in patients with deep wrinkles in lip Diff erential diagnosis for this type of cheilitis in- angles and those who are prone to licking lip corners8. cludes recurrent herpes labialis (if lesions are unilater- Generally, the disease starts during vitamin and min- al) and secondary syphilis (fi ssured papules at the cor- eral defi ciencies (B vitamins, iron, zinc, etc.), or is ners of the lips similar to cheilitis)2,9. Th erapy includes caused by other conditions and diseases (e.g., poorly elimination of predisposing factors and often topical fi tting dentures and drooling, celiac disease)4,6,9. An antimycotics, antiseptics, antibiotics, and sometimes important factor is also saliva production, i.e. increased corticosteroids. secretion and drooling, which contributes to the dis- Contact/eczematous cheilitis is an infl ammatory lip ease. Conversely, during decreased saliva secretion (hy- reaction caused by the irritating or allergic eff ects of posalivation), dryness promotes cracking and desqua- various substances found in
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