Cheilitis Simplex

Dryness, scaling and fissuring of the lips (cheilitis simplex). The lip vermilion has a thin stratum corneum, no sebaceous glands in most of its area, and no hair follicles, so it loses water quickly and has little protection from cold, wind and sun.

• Common causes:
  • Cold, dry or windy weather, low indoor humidity and air conditioning.
  • Habitual lip licking, biting or picking, and mouth breathing from nasal obstruction.
  • Dehydration, fever and sun exposure.
  • Contact allergy or irritation from lip balms, lipsticks, toothpaste flavourings, sunscreen, fragrance, lanolin, menthol, camphor, cinnamon, balsam of Peru, propolis and nickel on instruments.
  • Drugs: isotretinoin (almost universal), acitretin, vitamin A in excess, chemotherapy, diuretics and antihistamines.
  • Atopic dermatitis, Sjogren syndrome, Crohn disease, and deficiency of riboflavin, pyridoxine, vitamin B12, folate, iron and zinc.
  • Infection: Candida (angular cheilitis), staphylococci and herpes simplex.
• It affects all ages. Children who lick their lips develop a ring of redness around the mouth (lip lick dermatitis).

• Dry, tight, scaly lips with peeling, cracks and fissures, burning or soreness, and sometimes bleeding. The lower lip is affected most.
• Lip lick dermatitis shows a sharply marked, red, scaly band extending beyond the vermilion border onto the surrounding skin.
• Angular cheilitis shows red, fissured, macerated corners of the mouth.
• Contact cheilitis shows redness, swelling, scaling and itch of the whole lip, often with perioral skin involvement.
• Red flags:
  • An ulcer, erosion, white patch or hard area lasting more than 3 weeks (actinic damage or squamous cell carcinoma).
  • Fever for 5 days or more with red, cracked lips, red eyes and rash in a child (Kawasaki disease).
  • Lip swelling with facial nerve palsy and a fissured tongue (Melkersson-Rosenthal syndrome).
  • Mucosal crusting and blistering after a new drug (Stevens-Johnson syndrome).
  • Grouped vesicles (herpes simplex).
• Differential diagnosis: actinic cheilitis, herpes labialis, lichen planus, discoid lupus erythematosus, cheilitis glandularis, granulomatous cheilitis, plasma cell cheilitis, perioral dermatitis, vitamin deficiency and oral candidiasis.
• Complications: painful fissures, secondary bacterial or candidal infection, bleeding and post-inflammatory pigmentation.

• Clinical. Ask about licking and biting habits, mouth breathing, all lip, cosmetic and toothpaste products, drugs, occupational exposures, sun exposure and diet.
• Patch testing (including a lip product and dental series) when the lips stay inflamed despite emollients, or when contact allergy is suspected.
• Swab for Candida and bacteria in angular cheilitis or crusting.
• Full blood count, ferritin, vitamin B12, folate, zinc and glucose in persistent disease or suspected deficiency.
• Biopsy for any lesion that is indurated, ulcerated, white, or not healed in 3 to 4 weeks despite treatment.

• Remove the cause: stop licking and biting (habit reversal, barrier ointment at night), treat nasal obstruction, increase fluid intake, use a humidifier, and stop suspect lip products. Switch to a flavour free toothpaste for 4 to 6 weeks if contact reaction is suspected.
• Emollients and protection:
  • White soft paraffin (petrolatum) applied thickly 4 to 6 times daily and at bedtime.
  • Lip balms free of fragrance, menthol, camphor, phenol and salicylic acid, since these can worsen dryness and allergy.
  • A balm with SPF 30 or more for outdoor use, reapplied every 2 hours.
• Inflamed or fissured lips: hydrocortisone 1% ointment twice daily for 5 to 7 days (up to 2 weeks), then emollient alone. Prolonged use causes thinning and perioral dermatitis.
• Steroid resistant cheilitis or lip lick dermatitis: tacrolimus 0.1% ointment twice daily for 2 to 4 weeks (off label), or pimecrolimus 1% cream twice daily.
• Angular cheilitis:
  • Candida: miconazole 2% gel or cream, or clotrimazole 1% cream, twice daily for 2 weeks. Nystatin 100,000 units/mL suspension 1 to 2 mL 4 times daily can be applied.
  • A combined miconazole 2% and hydrocortisone 1% product twice daily for 1 to 2 weeks is useful when inflammation is marked.
  • Staphylococcal: mupirocin 2% ointment 3 times daily for 5 to 7 days.
  • In denture wearers, treat denture stomatitis and clean dentures (soak overnight in chlorhexidine 0.2% or dilute hypochlorite, and remove at night). Refer for correction of fit if the folds at the mouth corners are deep.
• Herpes labialis: aciclovir 5% cream 5 times daily for 4 to 5 days, or valaciclovir 2 g orally 12 hourly for 1 day, or famciclovir 1.5 g orally as a single dose, started at the first tingling.
• Drug induced cheilitis (isotretinoin): heavy emollient use, and a dose reduction in consultation with the prescriber if intolerable.
• Correct deficiencies found: oral iron (for example ferrous sulphate 200 mg orally once or twice daily), vitamin B12, folate 5 mg daily, riboflavin, or zinc sulphate 220 mg (50 mg elemental) daily for a limited course.
• Special groups:
  • Infants and children: petrolatum, avoid long term steroid, and treat the licking habit.
  • Pregnancy: petrolatum, brief hydrocortisone 1%, topical clotrimazole or miconazole are acceptable.
  • Elderly: check dentures, hydration, and nutritional deficiency.
  • Immunosuppression: consider candidal and herpetic infection early.
• Follow up: review at 2 weeks. If there is no improvement by 4 weeks, or any ulcer or induration appears, biopsy and refer to dermatology or oral medicine.