Lips diseases and its

management
Classification of Lip Disorders
Developmental
Congenital lip pits
Commissural lip pits
Double lip
Cleft lip and cleft palate
Cheilitis
Glandular cheilitis
Granulomatous cheilitis
Angular cheilitis
Contact cheilitis
Eczematous cheilitis
Actinic cheilitis
Exfoliative cheilitis
Plasma cell cheilitis
Cheilitis due to drugs
Carcinoma of lip
Miscellaneous
Chapping of lips
Actinic elastosis
Lip ulcers due to caliber persistent artery

Development of Lip
In the sixth week of intrauterine life, two medial nasal processes merge in midline. This will form
intermaxillary segment which will give rise to center of upper lip.
In adult, center of upper lip forms philtrum. Philtrum is bound laterally by two vertical ridges
under the nostril. Lateral part of upper lip fissure presents in maxillary process. This may lead to
cleft formation if it is not covered by epithelium and fused. Upper lip is thus formed from one-third
 medial nasal process and two-third maxillary process.
Anatomy
Mucocutaneous junctionlips are fleshy folds lined by skin externally and mucous membrane
internally. The upper and lower lips close along the red margin which represents the
mucocutaneous junction.
Surface the lips are covered with skin on the external surface and mucous membrane on the
inner surface, which has profuse salivary glands.
Extent the lip extends from the lower end of the nose to the upper end of the chin.
Nasolabial groove the upper lip borders onto the nose and is separated from the cheek by a
variably deep groove called as nasolabial groove.
Lower lipthe lower lip is separated from the chin proper by a more or less sharp and deep
groove that is convex superiorly called as labiomental groove.
Oral cornmissureit is the angle where the upper and lower lip meets.
Philtruni the upper lip includes the philtrum, a midline depression, which can be followed to
the nose.
Contenteach lip mainly consists of bundles of striated muscle, orbicularis oris, superficial
fascia and submucosa. The skin of the lip contains sweat glands, hair and sebaceous gland. The
dermal papillae are numerous, with rich capillary supply, which produce reddish pink color of the
lips.
Vermilion zoneit is the transitional zone between the skin and the mucous membrane. The
vermilion zone contains no hair or sweat glands and contains a few sebaceous glands. In some
people, sebaceous glands may be seen as creamy yellow dots. Fordyce's spots along the border
between vermilion border and the oral mucosa can also occur.
Blood supply of lipssubmental artery to the lower lip and inferior and superior labial arteries
to the upper lip.

Venous drainageanterior facial vein and its branches corresponding to the facial artery
provides the venous drainage of lips.
Lymphatic drainagefrom central part of lower lip, lymphatics drain to the submental
node and rest of the lip to submandibular nodes.
Nerve supplymental nerve and superior labial nerve.

Developmental Disorders of Lip

Congenital Lip Pits

It is also called as 'paramedian lip pit or congenital fistula'.
Etiopathogenesis
Hereditaryit is inherited as an autosomal dominant trait.
Notching of lipthere is notching of lips at an early stage of development with fixation of
tissues at the base of the notch.
Incomplete union it may occur due to failure of complete union of embryonic sulci of the lip,
resulting in persistent lateral sulci on the embryonic mandibular arch.
Clinical Features
 Sex predilectionit is more commonly seen in females.
Siteit is common on vermilion border of either side of midline. It is most commonly seen
on lower lip. Lip pits or fistula is unilateral or bilateral depression.
Size it may be upto 3-4 mm in diameter and may extend as deep as 2 cm.
Appearancelips,some times appear swollen, accentuating the appearance of the pit.
Palpationon palpation, sparse mucus secretion may be visible from the base of the lip-
pit which occurs due to involvement of underlying minor salivary glands.
Syndromes associatedcongenital lip pits may occur in association with Van der Woude's
syndrome (cleft lip, cleft palate and congenital lip pits). Another syndrome is associated
with it is popliteal pterygium syndrome which also includes Popliteal webbing (pterygia),
cleft lip / cleft palate, genital abnormalities and congenital bands connecting the upper and
lower jaws (syngnathia).

Diagnosis
Clinical diagnosisunilateral or bilateral depression on vermilion border of lip will diagnose
these conditions.

Management
Surgical excisionit is done for cosmetic purpose.
Commissural Pits
Commissural lip pits are mucosal invagination occurring at the vermilion border of lip.

Pathogenesis
They occur due to failure of normal fusion of embryonal maxillary and mandibular processes. It
is transmitted as autosomal dominant transmission.
Clinical Features
Sex distributionit is more common amongst males and black people are affected more than
white people.
Siteif it is unilateral, it occurs on the right side of the lip.

Appearance commissural pit appears as aunilateral or bilateral pit at the corner of the mouth
on the vermilion surface.
Sizesize ranges from a shallow dimple to a tract measuring 4 mm in length and tissue
slightly raisedabove the opening.
Palpationin squeezing of the lip pit, small amount of saliva can come out.

Differential Diagnosis
Congenital lip pitit may be associated with facial or palatal cleft.

Management
Surgical excisionit is indicated only in severe condition, where salivary secretion excessive and
 secondary infection can occur.

Double Lip
It is an anomaly characterized by a fold of excess tissue on the inner mucosal surface of the lip. It
may be congenital or acquired because of trauma to the lip.
Pathogenesis
It occurs in 2nd or 3rd week of gestation due to persistent of the sulcus between the pars glabrosa
and pars villosa of the lip.
Clinical Features
Siteit usually occurs on inner aspect of upper lip.
Cupid bow appearancewhen upper lip is tensed, double lip resembles 'cupid bow'.
Syndromes associatedit is associated with Ascher's syndrome which consists of double
lip, blepharochalasis (it is drooping of the tissue between eyebrow and edge of the upper
eyelid so that it hangs loosely over the margin of the lid) and non-toxic thyroid enlargement.
Diagnosis
Clinical diagnosiscupid bow appearance is typical.

Management

Surgical excision.

Cleft Lip and Cleft Palate

It occurs along many planes as a result of fault or defect in the development.

Definition
Cleft Lipit is a birth defect that results in a unilateral or bilateral opening in the upper lip
between the mouth and the nose. It is also called as harelip. It is wedge shaped defect resulting
from failure of two parts of the lip to fuse into a single structure.
Cleft palatecleft palate is a birth defect characterized by an opening in the roof of the mouth
caused by a lack of t:ssue development.
Development of Cleft
In.general, patients with clefts have a deficiency of tissue and not merely a displacement of
normal tissue.
Unilateral cleft lipAcleft lip occurs when an epithelial bridge fails, due to lack of
mesodermal delivery and its proliferation from the maxillary and nasal processes. It results
from failure of maxillary process on one side to meet and fuse with medial nasal process.
This will lead into the division of lip into medial and lateral part. It again occurs due to
absence or deficiency of mesodermal masses or their failure to penetrate the ectodermal
 grooves lead to breakdown of the ectoderm, causing cleft formation. In unilateral cleft lip,
the floor of the nose communicates freely with the oral cavity, maxilla on the cleft side is
hypoplastic, columella is displaced to the normal side and the nasal ala on the cleft side is
laterally, posteriorly and inferiorly displaced.
Bilateral cleft lipin this, medial mass interposed between two maxillary processes
grows down from lateral areas form above the maxillary process. In bilateral cleft lip, the
central portion of the alveolar arch is rotated anteriorly and superiorly.
Median cleft lip it results from partial and complete failure of the medial nasal process to
merge. The cleft of lip occurs earlier and inhibits tongue migration, which maw then
prevent horizontal alignment and fusion of the palatal shelves.
Median cleft of mandibular lip it occurs due to failure of mesenchymal masses of
mandibular process to merge together at 5 weeks of intrauterine life.
Cleft of primery palate clefts of primary palate occur anterior to the incisive foramen. Clefts
of secondary palate are due to lack of fusion of the palatal shelves and always occurs posterior
to the incisive foramen. Cleft palate occurs due to disturbances in normal fusion of palatal
shelves. This may occur due to failure to unite due to lack of force, interference by the tongue
or a disparity in the size of parts involved. It results from failure of the lateral palatine
process to meet and fuse with median palatine process. Inpalatal clefts, the muscles of soft
palate are hypoplastic and insert in the posterior margin of the remaining hard palate rather
than the midline raphe.
Cleft of secondary palateThe secondary palate closes one week later in females, which
may explain why isolated clefts of the secondary palate are more common in females. These
are clefts posterior to the incisive foramen. They result of partial or complete failure lateral
palatine process to meet, fuse and merge with each other.
Cleft of primary and secondary palatethey result of failure of growth or lack of fusion of
three palatine processes with nasal septum and each other.
Etiology
Hereditaryit is one of most important factors to be considered in the etiology.
Geneticthe main possible mode of transmission is by a single mutant gene; producing a large
effect or by number of genes (polygenic inheritance), each producing small effects which
together create this condition.
Nutritional disturbancesriboflavin deficient diet can produce cleft palate and cleft lip.
Developmentalphysiological, emotional and traumatic stress during developmental stages.
Defective vascular supplydefective vascular supply to the area may lead to ischemia
which in turn may lead to cleft formation.
Mechanical disturbanceshere, the size of tongue may prevent union of the parts.
Infectioninfection and lack of inherent developmental force.
Miscellaneoussteroid therapy during pregnancy, alcohol, toxins in the circulation.
Classification
First Classification
Unilateral incomplete.
Unilateral complete.
Bilateral incomplete.
 Bilateral complete.
Second by veaus
Cleft lip
Class IA unilateral notching of vermilion border and it is not extending into the lip.
Class II a unilateral notching of vermilion with cleft extending into lip but not including the
floor of the nose.
Class IIIa unilateral cleft of vermilion extending into the floor of the nose.
Class IVany bilateral cleft of the lip, whether this is complete or incomplete.
Cleft palate
Class Iinvolving only soft palate.
Class IIinvolving soft and hard palate but not alveolus.
o Class Illinvolving soft and hard palate and alveolus of one side.
Class IVinvolving both the soft and hard palate and alveolus on both sides of the pre-
maxilla.
Third by Kernahan and Stark
Unilateral incomplete cleft of the primary palate.
Complete cleft of primary palate ending at the incisive foramen.
Bilateral complete cleft of the primary palate.
Incomplete isolated cleft of the secondary palate.
Complete cleft of the secondary palatesoft and hard palate.
Unilateral complete cleft of the primary and secondary palate.
Bilateral complete cleft of the primary and secondary palate.
Incomplete cleft of the primary palate and incomplete cleft of the secondary palate.
Clinical Features
General
Sexit is more common in males as compared to females. But incidence of isolated cleft palate is
seen more in females.
Siteit is more frequently seen on the left side than on the right side. Left side is involved in 70%
of the cases. Cleft of mandibular lip or jaws are rare.
Appearance a typical patient with cleft palate, cleft lip and ridge exhibits a large defect with a
direct opening in the nasal cavity.
Teeth disturbances in the dental structures are seen in this region so that teeth may be
missing, deformed, displaced or divided, thus producing supernumerary teeth.
Cleft lip
There is nasal distortion as lip and nasal tissue pulls towards the attached side.

Hare lipthis term is used to apply for only median cleft lip. Hare lip is derived from the rabbit
who normally have cleft in the middle of their lip.

Unilateral cleft lip- a unilateral cleft involves only one side of the lip.

Bilateral cleft lip cleft lip is present on the both sides of the midline.

Incomplete cleft- it extends for varying distances forward to the nostril, but not upto
the nostril. The upper part of lip has fused normally.
Complete cleft lipit extends into nostril and palate is commonly involved. It is often
associated with flattening and widening of the nostril of the affected side.
Symptomspatient may be presented with difficulty in sucking. Patient also noticed
 defective speech particularly with the labial letters B, F, M, P and V.
Effect on tonguethere is soft tissue mass between the ends of the bone, uniting the tongue to
the lip, so that tongue is bound down.
Cleft palate
Site- may be cleft of the hard and soft palate or in some cases, cleft of soft palate alone. Entire pre-
maxillary portion of bone may be missing and in such instances, the cleft appears to be entirely
a midline defect.
Extentcleft of palate may also vary in severity, involving uvula or soft palate or extending
all the way through the palate (Fig. 23-8) and indirectly to the alveolar ridge on one or both
sides.
Symptoms- eating and drinking are difficult due to regurgitation of food and liquid through
the nose. Speech problem is serious and teends to increase due to mental trauma.
Defect in smelling it is due to contamination of the nasal mucous membrane with the oral
organism through the cleft palate.
Teeth the alveolar cleft interefers with the dental lamina. This will result in small upper
lateral incisors, absent or even duplicate. Cross bite due to medial collapse of premaxilla.
Associated anomaliesisolated cleft palate is associated with other developmental abnormalities
like congenital heart disease, polydactyly and syndactyly, hydrocephalus, micro-cephalus,
clubfoot, supernumerary ear, Spina bifida, hypertelorism and mental deficiency. Airway
problems may arise in children with cleft palates, especially those with concomitant structural
functional anomalies.
Syndrome associatedmost common syndrome is Pierre-Robin syndrome is the combination of
micrognathia, cleft palate and glossoptosis. Patients may develop airway distress from their
tongue becoming lodged in the palatal defect. Other syndromes which can be present are
Goldenhar syndrome, median cleft face syndrome, oral facial digital syndrome, Perts syndrome,
Nagar syndrome, otopalatodigital syndrome , Down's syndrome, and Marfan's syndrome.
Radiographic Features
It will determine presence and absence of unerupted teeth. The most common missing teeth
are maxillary lateral incisors. There is also presence of supernumerary teeth. Teeth are
malformed and poorly positioned.
There is also malposition of the teeth in the region of cleft or in the whole maxilla.
It will reveal the extent of osseous deformity. There may be complete separation of the premaxilla
and maxilla.
Diagnosis
Clinical diagnosis- cleft ca be seen clinically on lip and palate.
Radiological diagnosis- cleft palate involving alveolus is seen clearly on radiography.
Management
The complete rehabilitation of the condition requires a multi-disciplinary approach.
Cheiloplastyit is surgical closure of the lip. A general 'rule of tens' is used in determining
optimal timing of lip closure, i.e. 10 weeks of age, 10 pounds of body weight and 10 gm of Hb. At
the time of lip closure, when an infant is under general anesthesia, an impression is made for
the new obturator.
 Obturatorbetween 3rd and 9th months of age, an obturator is used to provide cross-arch
stability, support and to prevent collapse of maxillary arch.
Palatoplastyit is performed to close an opening in the palate. Surgeons may close the palate
in one surgery, when the child is about one year of age or the palate may be closed in two stages,
the soft palate is closed first followed by the hard palate.
Bone graftingsometimes, closure of palatal cleft may be done by bone grafting.
Orthodontic therapy orthodontic therapy is done to correct malocclusion.
Cleft rhinoplastyto improve nasal function and correct the distortion.
Speech therapyspeech therapy is given to improve pronounciation of the words.
Psychotherapypsychological management is necessary.
Feeding plateto overcome initial feeding problems, feeding plate is used which acts as an
obturator to prevent nasal reflux.

Cheilitis
It is inflammation of lip. Various types of cheilitis are described below.

Glandular Cheilitis or OrofacialGranulomatosos

It is also called as cheilitis glandularis. It is an uncommon condition in which lower lip becomes
enlarged, firm and finally everted.
Etiology
Sun exposureglandular cheilitis can occur due to chronic exposure to sun.
Hereditaryfamilial occurrence, suggesting a hereditary pattern is also present in glandular
cheilitis.
Salivary gland inflammationinflammation of enlarged heterotopic salivary glands can also be
causative factors.
Others dust, tobacco use and emotional disturbances also been reported in this patients.
Types (Historical)
Simple multiple, painless, pinhead sized lesions with central depression and dilated canals
are present.
Superficial suppurative type (Baelz's disease)it is characterized by painless swelling,
induration, crusting superficial ulceration of lip.
Deep suppurative type (cheilitis glandularis apostematosa, myxadenitis labialis)deep seated
infection with abscess and fistula tract that eventually forms a scar.

Clinical Features
Ageit is more common in adults but sometimes, it can also occur in children.
Sitelower lip is involved more often than the upper lip.
Symptomsenlargement of labial salivary glands occurs which can be nodular.
Signsorifices of secretory ducts are inflamed and dilated appearing as small red macules over
 the mucosa.
Palpationviscid mucous secretion may seep from these openings of everted hypertrophic lips
after pressure given on the lip.
Volkmann's cheilitisit is more severe suppurative form of glandular cheilitis. The lip is
considerably and permanently enlarged and is subjected to episodes of pain, tenderness and
increased enlargement. The surface is covered by crust and scales beneath which the salivary
duct orifice may be discovered.

Malignant transformationit is apparently pre-malignant and epidermoid carcinoma can be

associated with it in 18 to 35% of cases.
Diagnosis
Clinical diagnosiseverted hypertrophic lip with secretion after pressure on lip.

Management
Vermilionectomy or lip shavedue to high incidence of associated malignancy, a
vermilionectomy or surgical stripping of lips has been recommended. It will give satisfactory
cosmetic results.
Surgical excisionif the lips are grossly enlarged, excision of an elongated ellipse of tissue may be
required.

Granulomatous Cheilitis or Orofacial Granulomatosis

It is also called as 'Miescher's syndrome' or 'cheilitis grantilomatosa' .This condition is described
in 1945 by Miescher. It is a condition of unknown etiology that is not related to chelitis glandularis
except by the similarity in the clinical appearance of the two diseases.
Etiology
Local causes
Chronic oral / dental infection
Embedded foreign material
Allergy to cosmetics, foods, oral hygiene products and dental restorative materials.
Systemic causes
Chronic granulomatous disease
Crohn's disease
Sarcoidosis
Tuberculosis

Clinical Features
Age and sexit is seen in adults as well as in children and there is female predilection.
Symptoms
There is diffuse swelling of the lips, especially the lower lip .
In some cases, an attack is accompanied by fever and mild constitutional symptoms including
 headache and even visual disturbances.
Enlarged lip can create cosmetic problems, difficulty during eating, drinking or speaking.

Signsin some cases, scaling, fissuring and vesicles or pustules have been reported.

Palpationthe swelling is usually soft and exhibits no pitting on pressure. Swelling eventually
becomes firmer and acquires the consistency of that of hard rubber.

Lymph nodesthe regional lymph nodes are enlarged in some cases, but not always.

Skinthe skin and adjacent mucosa may be of normal color or erythematous.

Syndromeit is associated with Melkersson Rosenthal syndrome which consists of fissured

tongue and facial paralysis.

Diagnosis

Clinical diagnosissoft swelling of lip with fever, headache and vesicle can be seen.

Differential Diagnosis
Cheilitisglandularisin this condition there is involvement of labial salivary gland.
Angioedema it is recurrent condition and swelling subsides after giving antihistaminic.
Sarcoidosissymptoms of fatigue and lethargy are present.
Crohn's diseasegastrointestinal symptoms are present in this case.
Lymphangiomait is congenital lesion.
Management
Corticosteroid injectionrepeated injection of triamcinolone into the lips every few weeks
may be effective. Before giving steroids, topical anesthetics gels was applied over the lesion
and then 0.1% of triamcinolone acetonide injection is given. This injection should be given
weekly for 7 to 10 weeks.

Cheiloplastysurgical stripping of lip can be done.

Angular Cheilitis
It is also called as 'Perleche', 'Angular cheilosis"Cheilocanclidiasis'.

Causes
Microorganismsparticularly candida albicans, but also staphylococci and streptococci.
 Mechanical factorsoverclosure of jaws such as in edentulous patients or in patients with
artificial denture which lack proper vertical dimensions. In it, folds are produced at the corners
of the mouth in which saliva tends to collect and the skin becomes macerated, fissured and
secondarily infected. Prognathism may give rise to similar state of affair in young. The recurrent
trauma from dental flossing may occasionally be also implicated.
Nutritional deficiencyit can also occur due to riboflavin, folate and iron deficiency with a
superimposed fungal or bacterial infection. General protein deficiency can also cause cheilitis.
Diseases of skin- atopic dermatitis involving the face is often ,associated with angular cheilitis.
The incidence also appears to be increased in seborrhoeic dermatitis.
Other factorshypersalivation, Down's syndrome, large tongue and constant dribbling being
the contributory factors. A rare cause is the presence of a sinus of developmental origin at the
angles of the mouth.

Clinical Features
Ageit occurs in young children as well as in adults.
Symptoms- it is characterized by feeling of dryness and a burning sensation at the corners of
the mouth.
Appearanceit is usually a roughly triangular area of erythema and edema at one or more,
commonly both the angles of mouth.
Signsepithelium at the commissures appears wrinkled and somewhat macerated .In time,
wrinkling becomes more pronounced to form one or more deep fissures or cracks which appear
ulcerated but do not tend to bleed, although a superficial exudative crust may form.

Rhagadeslinear furrow or fissures radiating from the angle of mouth (rhagades) are seen in
more severe forms, especially in denture wearers.
Prognosis if the lesion is not treated, they often show a tendency for spontaneous remission.
Diagnosis
Clinical diagnosistriangular area or erythema with wrinkled macerated mucosa at angle of
mouth.
Management
Removal of the causeunderlying primary cause should be identified and treated.
Nutritional supplement a course of vitamin B and iron supplements are useful in these cases.
Fusidic acid ointmentit is used in staphylococcal infection. The lesions should be swabbed
first and then fusidic acid ointment or cream should be applied at least four times a day.
Miconazolemiconazole may be preferred, if angular cheilitis is due to candidiasis (cream
applied locally together with an oral gel).

Gentian violet applicationin some cases, it is useful.

Eczematous Cheilitis
The lips are involved secondary to atopic eczema but possibility of contact dermatitis must also
be considered. The management of atopic eczema of the lips is with emollient and topical
steroids.
 Contact Cheilitis
Definition
Contact cheilitis is an inflammatory reaction of the lips provoked by the irritants or sensitizing
action of chemical agents in direct contact with them.

Causes
Lipsticksthey are composed of mineral oils and waxes which form the stick; castor oil as a
solvent for the dyes, lanolin as an emollient preservative, perfumes and color. The color includes
azo dyes and eosin, which is a bromofluorescein derivative. Sunscreen applied in the form of
lipstick can also cause contact cheilitis.
Lipsalves and other medicamentslipsalves containing lanolin are frequently applied for
dryness
cheilitis.or chapping. Phenyl salicylates and antibiotics have also been incriminated as a cause of
Mouthwashes
and and
bactericidal dentifricesessential
agents canwhich
causehas oils
cheilitis. such asderived
Propolis, peppermint,
from cinnamon, clove, spearmint
resin and collected by bees,
is a well known sensitizer been used in toothpastes.
Dental preparationsmercury and eugenol may cause cheilitis in the absence of stomatitis.
Allergy to epimine containing materials used for crowns and bridges can cause cheilitis.
Foodsoranges, mangoes and artichokes are among the food plants which occasionally cause
allergic cheilitis and dermatitis of the skin around the lips.
Miscellaneous objectsmetal hair clips, metal pencils, cobalt paint on blue pencil can also
cause cheilitis. Clinical Features
Sitelipstick cheilitis is usually confined to the vermilion borders but more often extends
beyond that.
Signs and symptomsthere may be persistent irritation and scaling or a more acute reaction
with edema and vesiculation.

Diagnosis
If acute eczematous changes are obviously present, the diagnosis of contact cheilitis presents no
difficulty. If an allergic reaction is suspected, patch test can be carried out.

Management
Topical steroids will give symptomatic relief but the offending substance must be traced and
avoided. Most commonly used topical steroids use is 1% triamcinolone acetonide.

Actinic Cheilitis
It is also called as Actinic cheilosis. Some other terms which use are Farmer's lips or Sailor's lip as
these people are mom exposing to sunlight.

Definition
It is a pre-malignant squamous cell lesion resulting from long-term exposure to solar radiation and
may be found at the vermilion border of lip as well as other sun exposed surfaces.

Etiology
 Chronic sun exposureit is the main cause, so it usual::occurs in hot, dry regions, in outdoor
workers and fair skinned people.
Clinical Features
Sitethe lower lip is more commonly affected than the upper lip as it receives more solar
radiation than the upper lip.
Age and sex distributionit is more commonly seen in adult's patient. It is less common in
females due to sunscreen effect of lipstick and less common in blacks due to protective effect of
melanin.
Signsin the early stages, there may be redness and edema but later on, the lips become dry
and scaly. If scales are removed at this stage, tiny bleeding points are revealed. With the
passage of time. these scales become thick and horny with distinct edge. Patient can remove
scales but it again reforms within few days. Epithelium becomes palpably thickened with small
grayish white plaques. Vertical fissuring and crusting occurs, particularly in the cold weather.
Marginthere is blurring of the margin betwee vermilion zone and cutanous portion of lip.

Superficial erosionat times, vesicle may appear which rupture to form superficial erosions.
Secondary infection may occur.

Nodule formationeventually warty nodules may form which tend to vary in size with
fluctuation in the degree of edema and inflammation.
Signs of malignant transformationthe possibility of malignancy must always be considered
if following features are present;
Ulceration in actinic cheilitis.
A red and white blotchy appearance with an indistinct vermilion border.
Generalized atrophy or focal areas of whitish thickening.
Persistent flaking and crusting.
Indurations at the base of keratotic lesion.
Diagnosis
Clinical diagnosisredness, edema with history of chronic sun exposure will give clue to
diagnosis.

Management
Topical fluorouracilfor mild cases, application of 5% fluorouracil three times daily for 10
days is suitable. It produces brisk erosion but lips heal within 3 weeks. Application of 5-
fluorouracil to the lip will produce erythema, vesiculation, erosion ulceration, necrosis and
epithelialization. In some cases, podophyllin is also used.
CO2 snowrapid freezing with CO: snow or liquid nitrogen on swab stick is used to remove
superficial lesions.
Vermilionectomy (lip shaves)under local anesthesia, the vermilion border is excised by a
scalpel and closure is then achieved by advancing the labial mucosa to the skin. Postoperative
complications include paresthesia, lip pruritis and labial scar tension.
Laser ablationcarbon dioxide laser therapy has been used to vaporize the vermilion. Good
results with no postoperative paresthesia or significant scarring have been reported.
 Electrodesiccationit refers to the deeply penetrating tissue dehydration produced by the
insertion of electrodes into the tissue.
Preventionfollowing management, prevention of recurrence by regular use of sunscreen lip
salves is advisable. Liquid or gel waterproof preparation containing para-aminobenzoic acid
probably gives the best protection.

Exfoliative Cheilitis
It is also called as Factitious cheilitis. It is a chronic superficial inflammatory disorder of the vermilion
border of lips characterized by persistent scaling and flaking.

Causes
Chronic injurythese cases may occur due to repeated lip sucking, chewing or other
manipulation of the lips.
Personality disordersemotional disturbance, psychological difficulties and stress can also
lead to exfoliativecheilitis.

Clinical Features
Age and sex distributionage of occurrence is seen in younger group. Most cases occur in
girls.
Sitethe process starts in the middle of the lower lip and spreads to involve the whole of the
lower lip or both the lips.
Symptomsthe patient complains of irritation or burning and can be observed frequently on biting
or sucking the lips.
Signsit consists of scaling and crusting, more or less confined to the vermilion borders and
persisting in varying severity for months or years.
Perioral skinthere is erythema of perioral skin.

Diagnosis
Clinical diagnosisScaling, crusting with perioral skin erythema will aid to diagnosis.
Management
Reassurance and psychotherapythis is done to overcome personality disorders. After this, many
patients get relief.
Topical steroidshydrocortisone cream is useful in resolving some chronic cases in some
patients.
Combination hydrocortisone can be combined with iodoquinol (antibacterial and
antimycotic) cream can be used in chronic cases of exfoliativecheilitis.
Others therapy it includes topical silver nitrate, salicylic acid, antibacterial and antifungal
formulation.
Plasma Cell Cheilitis
It is an idiopathic benign inflammatory condition characterized by dense plasma cell infiltrate in
the mucosa close to the body orifice.
Clinical Features
Siteit can affect penis, vulva, lips, buccal mucosa, palate, gingiva, tongue, epiglottis and
 larynx.
Signit presents as circumscribed patches of erythema ,usually on the lower lip in elderly
persons.
Diagnosis
Clinicalnot possible.
Laboratory on histopathological examination plasma cell can be seen.

Management
It responds to topical application of powerful steroids intradermal injection of triamcinolone.

Drug-induced Cheilitis
Hemorrhagic crusting of the lips is a feature of steven johnson syndrome which is commonly
caused by drugsl but, cheilitis can occur as an isolated feature of a drug reaction- either as a result
of allergy or a pharmacological effect.
The aromatic retinoids, etretinate and isotretinoin causes dryness and cracking of lips in most
patients.

Carcinoma of Lip
Squarnous cell carcinoma is the commonest malignancy, affect the vermilion zone. It occurs in light
skinned who have chronic exposure to sunlight.

Clinical Features
Age and sex distributionthere is peak appearance in and 7th decade of life. It is more
common in males compared to females.
Site- is most common on the lower lips of fair skinned people and persons who work in outer
climate.
Onsetit usually begins on vermilion border of lip to one side of the rnidline and it may be
covered crust due to absence of saliva.
Actinic cheilitisit is preceded by actinic cheilitis which is characterized by innocuous looking
white plaque:-the lip.
Symptomspatient may complain of difficulty in speech difficulty in taking food and inability to
close the mouth. There is also pain, bleeding and paresthesia.
Signs
It often commences as a small area of thickening, induration and ulceration or irregularity of
the surface.
In some cases, it commences as a small warty growth or fissure on the vermilion border of the
lip.
Crater like lesion having a velvety red base and rolled indurated borders.
As the lesion enlarged, it takes papillary or an ulcerative form.
 In untreated cases, there is total destruction of lip and invasion of cheek, the gums and the
mandible.

Extent- papillary lesion grows slowly and infiltrared the deeper relatively late whereas
ulcerative growth invade early.
Metastasisit may metastasize and it is usually ipsilateral. Carcinoma of the upper lip
metastasizes earlier and more frequently than carcinoma of the lower lip. It involves
submaxillarv and submental nodes first and then deep cervical nodes. Spread by direct
extension into surrounding structures and by metastasis which is through lymphatic
channels.

Diagnosis
Clinical diagnosisulcerative growth with destruction of lip is present.
Laboratory diagnosisit is mainly well differentiated malignancies.

Management
Surgicalprognosis is good if the treatment is done before metastasis.
The best results are seen when being obtained when the entire lip mucosal field is removed for
early lesion.

Miscellaneous Disorders
Chapping of the Lips
It is a reaction to adverse environmental conditions in which keratin of the vermilion zone loose
its plasticity.
Causesit is caused by exposure to freezing cold or to hot, dry wind, but acute sunburns can
cause very similar changes.
Clinical featureslip becomes sore, cracked and scaly. The affected subjects tend to lick the lips
or to pick at the scales which make conditions worse.
ManagementManagement is by application of petroleum jelly and avoidance of the causative
environmental conditions.
Actinic Elastosis
It is also called as 'Solar elastosis' or 'Senile elastosis'.

Causes

Sunlight exposure-it is caused by prolonged exposure to UV light. UV radiation can produce

collagen degeneration in the dermis and extent of this effect is dependent upon factors such
as the thickness of stratum corneum, melanin pigment, clothing or chemical sunscreens.
Clinical Features
 Site-it is seen on the labial mucosa exposed to sun.
Age-it occurs in elderly population.
Signs -white area of atrophic epithelium develops with underlying scarring of the lamina
propria.
Appearance-it includes leathery appearance, laxity with wrinkling and various pigmentary
changes.
Clinical types- clinically, it is manifested in three forms:

Cutis rhornboidalis - thickened skin with furrow giving an appearance of rhomboidal

network.
Dubreuilh'selastoma- diffuse plaque like lesions.
Nodular elastoidosis - nodular lesion.

Caliber Persistent Artery

A caliber persistent artery is defined as an artery with a diameter larger than normal near a
mucosal or external surface. In this condition, main arterial branch extends upto the superficial
tissue without reduction in the diameter is present.

Clinical Features
Age and sex distribution-it is more commonly seen in adults as in adults there is loss of
tone in the connective tissue.

Site- either lip can involve or some patients have bilateral lesion.
Appearance-the lesion present as linear, arcuate or papular elevation on the lip.
Ulcer formation-such artery in the lip may cause chronic ulceration which can be mistaken for
squamous carcinoma. The ulcer is attributed to continual pulsation from the large artery
running parallel to the surface.
Signs-pulsation can be seen in the lesion. Pulsation present in lateral direction.

Management
No treatment is necessary and some time, biopsy is to avoid the misdiagnosis of the
lesion.