P. Kenny, MB, BCh, FRCPC
Department of Dermatology, University of British Columbia, Vancouver, Canada
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.
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
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®).
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.
- 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.
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:
|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)|
|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|
|Red||History of nose bleeds||Rendu-Osler-Weber disease (hereditary hemorrhagic|
|Liver disease||Primary biliary cirrhosis|
|Brown||Intestinal polyps||Peutz-Jeghers syndrome|
|Blisters/erosions||Acutely ill||Erythema multiforme|
|Grey-white||Marked sun damage||Actinic cheilitis|
|Papulovesicles/ pustules||Scale||Perioral dermatitis|
|Swelling||Acute/short-lived urticaria elsewhere||Angioedema|
|Chronic, persistent||Granulomatous cheilitis|