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Exfoliative cheilitis is a chronic superficial inflammatory disorder characterized by hyperkeratosis and desquamation of the vermilion epithelium, with persistent scaling (Figure ). The diagnosis is restricted to those few patients whose cheilitis cannot be attributed to other causes such as contact sensitization or UV light . Aetiology Most cases occur in girls or young women, the majority of whom seem to have a personality disorder (Jeanmougin et al., 1984; Reade and Sim, 1986) and indeed, a psychogenic cause was proposed by the French, designating this "le tic des levres" to indicate manipulation as being the basis. A preoccupation with the lips is prevalent in some individuals. Many cases are thus thought to be factitious, caused by repeated self-induced trauma such as repetitive biting, picking, lip sucking, chewing or other manipulation of the lips (Thomas et al., 1983; Daley and Gupta, 1995). Exacerbations have been associated with stress. Some cases have improved with psychotherapy and antianxio-lytic or antidepressant treatment. In some cases the condition appears to start with chapping or with atopic eczema, and develops into a habit tic. There appears to be no association with dermatological or systemic disease, though some cases are infected with Candida species (Reade et al., 1982) and rare cases are seen in HIV disease. In one large Russian series, almost half the cases had associated thyroid disease (Kutin, 1970), but this observation has not been confirmed.
Clinical features:
Exfoliative cheilitis often starts in the centre of the lower lip and spreads to involve the whole of the lower or of both lips. The patient may complain of irritation or burning and can be observed frequently biting or sucking the lips. Lip scaling and crusting is more or less confined to the vermilion border, persisting in varying severity for months or years. There may be bizarre yellow hyperkeratotic (Figure ) or thick hemorrhagic crusts (Figure ). The sloughing of sheets of epithelium is another feature in some.
Diagnosis:
Similar superficial scaling can be present in actinic cheilitis, contact cheilitis, glandular cheilitis, lupus erythematosus, Candida infections and HIV infection. Contact and actinic cheilitis in particular must also be carefully excluded and biopsy is sometimes indicated.
Management:
Some cases resolve spontaneously (Postlewaite and Hendrickse, 1988; Daley and Gupta, 1995) or with improved oral hygiene (Brooke, 1978). Reassurance and topical corticosteroids may be helpful in others (Thomas et al., 1983) but often exfoliative cheilitis is refractory to treatment, even including topical fluorinated corticosteroids. Indeed, the peeling in some cases is accentuated by topical medications. When a factitial cause is suspected, a psychiatric consultation and care may be beneficial; some require psychotherapy, antidepressants or tranquillizers (Poslethwaite and Hendrickse, 1988; Crotty and Dicken, 1981).