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Diagnosis and Treatment of Lip Conditions for Family Practitioners

P. Kenny, MB, BCh, FRCPC
Department of Dermatology, University of British Columbia, Vancouver, Canada

Definition

Skin conditions are commonly found on the lips. Surrounding skin and mucosal surfaces may be involved, and hair problems may be present. Lesions can be single or multiple. Conditions can be localized or diffuse, with other features found upon physical examination that help to make a diagnosis. To patients, these conditions are not trivial, and for physicians they remain a challenge, though effective therapies are emerging.

Benign and Malignant Tumors

Benign and malignant tumors are usually easy to recognize:

  • Vascular lesions. Mostly pyogenic granulomas. Can be treated with cryotherapy, electrodesiccation, or excision.
  • Venous lakes are common in the older population. Can sometimes be confused with melanoma.
  • Multiple small vascular lesions are seen in hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease). May have frequent nose bleeds. Similar changes are with primary biliary cirrhosis.
  • A solitary brown, flat lesion that insidiously appears can raise the question of melanoma. However, if it is symmetrical in shape and uniform in color, it is probably benign, i.e., labial melanosis (labial freckle), found in fair-skinned individuals. If in doubt, do a biopsy.
  • Malignant tumors, especially squamous cell carcinomas (SCC), require prompt surgery; there is a higher metastatic rate for SCC on the lip.

Precancerous Lesions

Actinic keratoses. These lesions have rough, scaly surfaces and a history of intermittent sloughing and reforming. Therapy includes:

  • Cryotherapy, photodynamic therapy (PDT), topical fluorouracil 5% cream (Efudex®)
  • Imiquimod 5% cream (Aldara®)

Actinic cheilitis is often chronic and presents with grey-white scales mostly on the lower lip that can become erosive. The loss of the vermilion border is common. This lesion is seen among older males with a history of extensive sun exposure. SCC develops in a significant percentage of patients. Surgical removal of the lower lip is common treatment, but ongoing lower-lip tightness postsurgery can be distressing. Effective therapies include:

  • Cryotherapy, topical fluorouracil 5% cream b.i.d. or t.i.d. for 15 days
  • Imiquimod three times/week for 4–6 weeks

Inflammatory Lesions

Perioral dermatitis is a reaction on the skin surrounding the mouth that causes papules, papulovesicles, and pustules without comedones. It can affect children, but most commonly is seen in adult females. Its etiology includes atopic diathesis, reactions to cosmetic products, and use of fluorinated topical corticosteroids, including inhaled agents. Therapy involves:

  • Discontinuing corticosteroids
  • Metronidazole 0.75% cream (MetroCream®) or 1% cream (Noritate®) q.d. or b.i.d.
  • Tetracycline or erythromycin 250mg q.i.d. for 4–6 weeks

Herpes labialis is a recurrent and painful condition that can be treated by oral therapy. A recent one-day oral therapy may prove effective: valacyclovir (Valtrex®) 2000mg po every 12 hours for 24 hours. Topical prescription therapies include penciclovir cream 1%(Denavir®) and acyclovir cream/ointment (Zovirax®).

Diffuse Scaling

Cheilitis, or diffuse scaling of the lips, is caused by atopic dermatitis, contact dermatitis, and drug reactions. Atopic lip involvement responds to frequent emollient use and low-potency topical corticosteroids. Contact dermatitis can be allergic or irritant in type, and caused by lip gloss, dental hygiene products, or metal objects held by the lips. An under-appreciated cause is the habit of lip licking, which can be difficult to stop. Oral isotretinoin (Accutane®) for acne can cause persistent, dry, scaly lips.

Systemic Diseases

  • Discoid lupus erythematosus. Lesions are scaly papules, reddened with telangiectasias that may show whitish scars. Lesions respond to intralesional triamcinolone.
  • Erythema multiforme presents with erosive lesions on the lips, mucosal surfaces, palms, soles, and other sites. Patients are ill and very uncomfortable. A common trigger for this condition is a herpes simplex infection; it is important to rule out this condition when making the diagnosis. Other causes are drug reactions and other infections. Treat the underlying cause with oral corticosteroids.
  • Sarcoidosis causes granulomatous lesions to appear.
  • Peutz-Jeghers syndrome causes multiple brown-pigmented macules on the lips, which can indicate intestinal polyposis.

Hair Problems

Hirsutism is a condition of excessive hair that can occur on the skin of the lips. A new, convenient therapy for upper lip hair is topical eflornithine 13.9% cream (Vaniqa®) b.i.d. every 8 hours, with a response in 1–2 months. Eflornithine 13.9% cream inhibits ornithine decarboxylase and retards hair growth.

Summary of Diagnoses

A simple approach to diagnosis can be based on the features of lesions and hair problems:

Single Lesion

Additional Features

Think About

Red Bleeds easily Pyogenic granuloma
Scaling/ telangiectasias Discoid lupus
Grouped vesicles Crusting Herpes labialis
Purple Smooth surface Venous lake
Brown Scale/ white streaks Lichen planus
Smooth surface Labial melanosis (freckles)
Golden Crusting Impetigo
Impetigo Scale/ rough surface Actinic keratosis
Nodule/ tumor Verrucous-like Squamous cell carcinoma
Pearly Basal cell carcinoma
Flesh color Uneven surface Wart
Fissure Macerated scale Angular stomatitis

Multiple Lesions

Additional Features

Think About

Red History of nose bleeds Rendu-Osler-Weber disease (hereditary hemorrhagic telangiectasia)
Liver disease Primary biliary cirrhosis
Brown Intestinal polyps Peutz-Jeghers syndrome
Blisters/erosions Acutely ill Erythema multiforme
Grey-white Marked sun damage Actinic cheilitis
Yellow-white   Fordyce spots
Papulovesicles/ pustules Scale Perioral dermatitis

Diffuse Lesions

Additional Features

Think About

Swelling Acute/short-lived urticaria elsewhere Angioedema
Chronic, persistent Granulomatous cheilitis
Scaling   Atopic dermatitis
Lip licking
Isotretinoin