1. health and fitness
2. disease

PJMS- Volume 2 Number 1: January-June 2012
Case Report
Exfoliative cheilitis due to habitual lip biting and
excellent response to methotrexate
Gupta S1, Pande S2, Borkar M3
Abstract
1
Resident, 2Assistant Professor,
3
Professor,
Department of Dermatology,
NKPSIMS & RC, Digdoh Hills,
Hingna Road, Nagpur-440019
ahens86@gmail.com
Exfoliative cheilitis is a chronic superficial inflammatory disease of the vermilion border of the lips characterized by
continuous scaling. In majority of cases, cause of the disease is repetitive lip picking or biting which leads to excessive
production and exfoliation of keratin and hence it is also termed as facticious cheilitis. We hereby present a rare case
of a young male patient who developed exfoliative cheilitis secondary to continuous lip picking thereby resulting in
severe cosmetic disfigurement. Despite intensive counseling and anxiolytic therapy, the condition was unremitting.
Hence weekly methotrexate therapy (7.5mg/week) was initiated with excellent response at the end of one month.
Introduction
Figure 2:
Exfoliative cheilitis is a rare disease which affects the
vermilion border of the lips. It is characterized by unremitting
production and desquamation of thick scales of keratin (1,2).
Crusts may be attributed to self induced trauma such as
repetitive biting, picking or licking of the lips (3). Underlying
stress or psychiatric conditions may cause or exacerbate
exfoliative cheilitis which regress with psychotherapy and
anxiolytic-antidepressant treatment (1,3). This condition is
disabling as it causes cosmetic disfigurement and also affects
daily activities such as chewing and speaking (4). The lack of
specific treatment makes exfoliative cheilitis a chronic disease.
We present this report because of the rarity of the disease and
to demonstrate excellent results to methotrexate.
Marked
hyperkeratosis
with
lymphocytic
infiltration
examination, there were keratotic, painless, firm yellowish
white crusts over mucosa of the lower lip. Scaling and
erythema was noted over the upper lip. On removal of the
crusts, the underlying mucosa appeared erythematous. Oral
cavity, teeth and rest of the skin was normal. There was no
regional lymphadenopathy. Systemic examination revealed no
abnormality. However, on psychiatric evaluation, patient
admitted of repetitive lip picking. He was depressed due to
severe cosmetic disfigurement of lips. Routine blood
investigations were all within normal limits. An incisional
biopsy that included the normal mucosa and skin was
obtained. Histopathology revealed marked hyperkeratosis,
parakeratosis and minimal superficial perivascular
lymphoyctic infiltrate (Figure 2). No cellular atypia was
observed. Based on clinical examination and histopathologic
findings, patient was diagnosed as exfoliative cheilitis.
Case Report
A 23 year-old male presented to the Dermatology
department with chief complaints of yellowish white lesions
over the lower lip (Figure 1). Lesions were first noticed by the
patient 9 years back and gradually increased in size to involve
both lower lip and upper lip. There was history of biting and
picking of the lip. Patient had received multiple treatments in
the past with partial or no relief. Lesions were also refractory to
topical corticosteroids but minimal improvement was noted
following intralesional corticosteroids.
General examination was normal. On cutaneous
Treatment was started on weekly methotrexate (7.5
mg)along with folic acid 5 mg OD. After a month, significant
improvement of 50-75% was noted (Figure 3). The patient is
being maintained on the same therapy and is being followed
up to look for remission or relapse.
Discussion
Exfoliative cheilitis is a rare disease of the lip
characterized by visible desquamation of the lips. Although
Figure 1: Prominent scaling of lower lip on the erythematous base
37
PJMS- Volume 2 Number 1: January-June 2012
Case Report
Exfoliative cheilitis may resolve spontaneously, but if
persistent, it is usually refractory to treatment and difficult to
manage(6). Avoidance of lip sucking or biting and use of lip
moisturizers has been the mainstay of therapy. Psychiatric
evaluation is essential for diagnosing any emotional stress that
can exacerbate lesions (9). Successful management of such
patients as self-inflicted disorders of compulsivity-impulsivity
spectrum mostly benefit from selective-serotonin reuptake
inhibitors (7). However these agents, combined with intensive
counseling and psychotherapy have not yielded desired or
satisfactory results. Therefore, various therapeutic modalities
like cryosurgery, topical corticosteroids and keratolytic agents
have been tried in the past with variable outcomes. All of them
are aimed at reducing excessive keratin and provides
temporary and symptomatic relief. As our patient had severe
inconvenience and cosmetic disfigurement due to the disease,
we tried weekly methotrexate therapy to reduce excessive
epidermal proliferation. In our patient, significant
improvement in scaling and erythema was seen with
methotrexate therapy without any recurrence till date.
Figure 3: Reduction of scaling following methotrexate therapy
definite etiology is unknown, many believe it to be secondary
to compulsive or impulsive picking of the lips. As the disease is
self induced in majority of cases, it is also termed as facticious
cheilitis. Factitious illness behavior can be a maladaptive way
of coping with stress and does not necessarily imply an
ongoing factitious disorder. The disease is commonly observed
in young females but can be seen in any age group and
race(1,5,6). In our patient, the probable cause of the disease
was habitual picking and biting of the lips.
This case highlights the fact that exfoliative cheilitis is
secondary to compulsive lip licking and methotrexate can be
used as non-steroidal therapeutic option in severely affected
patients.
Atopy, actinic damage, cheilitis granulomatosa,
plasma cell cheilitis, contact dermatitis, discoid lupus
erythematosus and neoplasia should be considered in the
differential diagnosis of crusted and ulcerated lesions of the lip
(7,8). Thorough clinical history, basic laboratory tests and
histopathologic evaluation are required to exclude other
diseases.
References
1)
2)
Histologically, exfoliative cheilitis is characterized by
marked hyperkeratosis and parakeratosis without significant
inflammation. This could be reactive hyperplasia of the
epidermis due to repetitive trauma in the form of regular
picking of the lips. Trauma may induce epidermal proliferation
resulting in parakeratosis and hyperkeratosis. The chances
that any other factors like contact dermatitis, infectious
agents, neoplasia or autoimmune disease causing excessive
epidermal proliferation appear unlikely. Koilocytes or atypical
cells has been consistently absent in histopathology of
exfoliative cheilitis. Histopathology also helps in
differentiation of this entity from discoid lupus
erythmetaosus, lichenoid dermatoses, plasma cell cheiltis,
cheilitis glandularis, actinic cheilitis or neoplasia (7,8).
3)
4)
5)
6)
7)
8)
9)
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