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Exfoliative cheilitis

Cheilitis means inflamed lips. There are various causes.

What is exfoliative cheilitis?

Exfoliative cheilitis is a rare reactive condition presenting as continuous peeling of the lips. Factitial cheilitis may be the same condition or a subgroup of it. Some authors distinguish between exfoliative and factitial cheilitis: if the behaviour triggering the condition is attention-seeking (factitial) or obsessive-compulsive with no intent of gain (exfoliative).

Who gets exfoliative cheilitis and why?

Exfoliative cheilitis is rarely reported but appears to affect both sexes equally and mainly affects young adults less than 30 years of age. The most common presentation appears to be triggered by a stressful event and may involve an element of self-damaging behaviour.

Initiating or perpetuating factors identified in some patients include:

Poor oral hygiene has also been reported in association with exfoliative cheilitis and considered to be a possible predisposing trigger. One form of the condition is associated with HIV infection and due to Candida species.

Whatever the cause, excessive keratin formation results in the abnormal peeling.

Clinical features of exfoliative cheilitis

Exfoliative cheilitis presents with continuous peeling of the vermilion (outer) part of the lips. It may affect just one lip, usually the lower. The lip may look normal or red before the formation of the thickened surface layer. The peeling appears to be cyclical and proceeds at different rates in different sites, so there is always some part of the lip peeling at any time. There may be associated bleeding resulting in formation of a haemorrhagic crust. When both lips are involved, the lower lip is usually more affected than the upper.

Exfoliative cheilitis Exfoliative cheilitis
Exfoliative cheilitis

The condition may be painful, causing difficulty in eating and speaking. Other symptoms reported include sensations of:

Ulceration or fissuring may occur.

Depression and personality disorders have been reported commonly in association with exfoliative cheilitis. However the cheilitis itself can be of such unpleasant appearance that the patient avoids social situations, contributing to mood disturbance.

The typical course of exfoliative cheilitis is chronic over years. It may fluctuate, worsening with further stress. Spontaneous improvement has been reported, but it often recurs.

How is exfoliative cheilitis diagnosed?

As exfoliative cheilitis can look similar to other conditions, tests are required to exclude these other conditions. Swabs for infections including candida and a biopsy should be done. Exfoliative cheilitis is a diagnosis of exclusion and there is no specific diagnostic test for it. A careful psychiatric assessment can be especially helpful as treatment of an associated mood or anxiety disorder has been reported to also improve the cheilitis.

Treatment of exfoliative cheilitis

Unless a predisposing or associated condition can be identified and treated, exfoliative cheilitis is typically resistant to treatment. Unsuccessful use of keratolytic lip balms, sunscreen, antifungal creams, topical steroids, systemic steroids, antibiotics, and cryotherapy have been described. There has been one report each of the successful use of topical tacrolimus and Calendula officinalis (marigold) ointment 10%.

In the setting of immunodeficiency such as AIDS, antifungal treatment can be helpful if Candida species are identified on swabs from the lip.

Treatment of an associated mood or anxiety disorder has been reported to improve the cheilitis. Obsessive-compulsive disorders respond best to selective-serotonin-reuptake inhibitors, compared to factitial conditions. Anti-depressants have been reported to help but not clear the cheilitis.

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Author: Dr Delwyn Dyall-Smith FACD, Dermatologist.

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