EXFOLIATIVE CHEILITIS: REPORT OF TWO CASES

PRESENTING A MARKED CLINICAL IMPROVEMENT

AFTER ORAL OLANZAPINE
Tribó MJ*, Martinez Escala ME*, Ros-Montalban S**, Ros-Cucurell E**, Pujol RM*, Bulbena A**
Departments of Dermatology and Pathology*. Department of Psychiatry**. Hospital del Mar. IMAS. Barcelona. SPAIN

Introduction
The concept of exfoliative cheilitis (EC) defines a heterogeneous spectrum of chronic inflammatory processes characterized by a persisting crusting and desquamation of the
lips. It is a disorder presenting a female predominance and often develops before the age of 30 years. The etiology of EC is unknown, but a possible factitious origin has been
postulated. In the dermatological French literature this condition has been described as "le tic des lèvres", in which recurrent manipulation of the lips may lead to inflammatory
changes or to exacerbate pre-existing lesions. Histopathological features are often non-specific (epithelial hyperplasia and a mild inflammatory infiltrate surface). EC should be
differentiated from other disorders causing persistent cheilitis such as Candidal lip infections, atopic cheilitis, actinic cheilitis, and glandular cheilitis. Historically, the use of
dopamine receptor antagonists, such as aloperidol and pimozide, had been useful in the treatment of tics. The apparition of atypical antipsychotics, for instance olanzapine and
risperidone, has permitted us optimized the risk and benefit balance. We report two additional cases of exfoliative cheilitis showing a marked improvement was noted after
treatment with oral olanzapine.

Clinical cases
A 61-year-old woman was referred to our Department for evaluation of referred for one
year's history of angular cheilitis refractory to emollients and topical corticosteroids. Past
medical history disclosed an anxiety disorder causing motor automatisms treated with
antidepressant and anxiolytics. Physical examination revealed a thick yellowish brown
crusting on the lips extending to the vermillion border (Fig 1a, 1b). A complete haematological,
biochemical and immunological survey disclosed no abnormalities. Patch testing with the
European standard series was also negative. A punch biopsy specimen from the lower
lip disclosed (Fig 2) an epithelial and glandular hyperplasia with a mild perivascular
inflammatory infiltrate in the upper submucosa. No epithelial dysplasia was present. The
diagnosis of EC was established and treatment with oral olanzapine (5mg/day), alprazolam
(1mg/day) and lipoic acid (200 mg/day) were prescribed. A marked clinical improvement
(80%) was noted after four months of treatment (Fig 3).
A 18-year-old man presented a two month's history of persistent dryness and desquamation
of the lips. He has been treated with petroleum jelly and topical corticosteroids without
improvement. He dropped out school last year because of stress. The diagnosis of
anxiety disorder with obsessive traits and motor rituals was established. Physical
examination revealed a yellow brown crusting of the lips with whitish patches on the
mucous side (Fig 4). A bacteriological culture from the crusts isolated Candida albicans
and P. aeruginosa. Treatment with oral fluconazole and ciprofloxacin were prescribed
but no clinical improvement was noted. A completed haematological, biochemical and
immunological survey disclosed no abnormalities. Patch test results were also negative.
The clinical diagnosis of EC was established. Oral olanzapine (2.5 mg/day) was prescribed.
A marked and persistent clinical improvement of the lesions was observed after three
months.

Fig 4. Physical examination

revealed a yellow brown
crusting of the lips with
Fig 1a and 1b. A thick yellowish brown crusting on the lips extending to the whitish patches on the
vermillion border. mucous side.

Fig 2. An
epithelial and
glandular
hyperplasia
with a mild
perivascular
inflammatory Fig 5. A marked clinical
infiltrate in improvement after three
the upper Fig 3. Patient one improvement after four months of oral olanzapine
submucosa. months of treatment with olanzapine. treatment.

Conclusions

• EC seems to include a heterogeneous group of disorders: factitious cheilitis, cheilitis secondary to an impulsivity disorder and probably several inflammatory disorders
causing persisting lip desquamation (irritative cheilitis, allergic contact cheilitis, infectious disorders, etc).
• In some cases of exfoliative cheilitis underlying psychiatric disturbances may be detected.
• We reported two cases of persistent EC refractory to topical treatments in two patients with an underlying psychiatric disorder who recognized a possible self-inflicted cause
for the lesions.
• In both patients a marked clinical improvement was noted after treatment with oral olanzapine. No significant side-effect was noted.
• Oral olanzapine, an effective drug usually prescribed for the obsessive-impulsive disorder, may be an additional useful therapeutic option for patients with exfoliative cheilitis.

References
1. Aydin E, Gokoglu O, Ozcurumez G, Aydin H. Factitious cheilitis: a case report. J Med Case Report 2008;2:29-32.
2. Daley TD, Gupta AK. Exfoliative cheilitis. J Oral Pathol Med 1995;24.117-9.
3. Reade PC, Sim R. Exfoliative cheilitis - a factitious disorder? Int J Oral Maxillofac Surg 1986;15:313-7.
4. Taniguchi S, Kono T. Exfoliative cheilitis: A Case Report and Review of the Literature. Dermatology 1998;196(2):253-5.

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