Journal Article of Exfoliative Cheilitis successfully treated with topical tacrolimus

Hi Guys came across this article where the researchers claim to have cured the disease

British Journal of Dermatology

Volume 151 Issue 1 Page 241-242, July 2004

To cite this article: M. Connolly, C. Kennedy (2004)
Exfoliative cheilitis successfully treated with topical tacrolimus
British Journal of Dermatology 151 (1), 241–242.
doi:10.1111/j.1365-2133.2004.06043.x

CORRESPONDENCE
Exfoliative cheilitis successfully treated with topical tacrolimus

* M. Connolly and
* C. Kennedy

*
Bristol Dermatology Centre, Bristol Royal Infirmary, Bristol BS2 8HW, U.K. E-mail: connollymo@btopenworld.com

Sir, Exfoliative cheilitis is a chronic superficial inflammatory disorder of the vermilion borders of the lips characterized by persistent scaling; it can be a difficult condition to manage.1 Topical tacrolimus is a new immunosuppressive agent successfully used in atopic dermatitis.2-4 We report a case of recalcitrant exfoliative cheilitis that responded to treatment with topical tacrolimus.

A 41-year-old woman presented with lip dryness, soreness and peeling with episodes of bleeding over an 8-month period. She admitted to picking at her lips. There was no history of atopic dermatitis. On examination, she had dry lips with scaling and crusting particularly involving the vermilion border (Fig. 1a). A diagnosis of exfoliative cheilitis was made based on the history and clinical findings.

Investigations revealed a normal full blood count, serum ferritin on the lower side of normal at 17 µg L-1 (normal 15–400) and a negative lip swab. Contact allergic cheilitis was excluded by negative patch tests to the European standard series, facial and preservative series, oral series, perfumes and flavourings series as well the patient's own toothpaste and moisturizer.

Her symptoms persisted despite treatments with hydrocortisone cream, Fucidin® (Leo Pharmaceuticals, Princes Risborough, U.K.; fusidic acid 2%, hydrocortisone acetate 1%) cream, Fucibet® (Leo Pharmaceuticals; betamethasone 0·1%, fusidic acid 2%) cream, Daktacort® (Janssen-Cilag, High Wycombe, U.K.; hydrocortisone 1%, miconazole nitrate 2%) cream, Metrogel® (Novartis, Camberley, U.K.; metronidazole 0·75% gel), Eumovate® (GlaxoSmithKline, Uxbridge, U.K.; clobetasone butyrate) cream, Blistex® and soft white paraffin. The patient also made a conscious effort not to pick at or rub her lips. A 6-month course of iron supplementation was given but this also failed to improve her symptoms. Dermovate® (GlaxoSmithKline; clobetasol propionate 0·05%) ointment used sparingly twice daily for 3 weeks alleviated her symptoms but the cheilitis recurred upon stopping the treatment. In view of the long-term risks of applying a highly potent steroid to the face and the intractability of her symptoms it was decided to initiate treatment with topical tacrolimus (Protopic®; Fujisawa, London, U.K.) ointment 0·1% twice daily, and within 4 weeks the cheilitis had cleared (Fig. 1b). In view of the excellent response to therapy the tacrolimus was reduced to once daily for a further few weeks and then to alternate days. The patient now remains symptom-free by using tacrolimus only when her symptoms flare. No adverse effects from topical tacrolimus were noted in this patient.

Exfoliative cheilitis is a condition in which the lips are chronically inflamed, crusted and somewhat fissured. In these patients, it is important to exclude contact sensitization, infection or light (actinic cheilitis) as causal agents. It is also known as factitious cheilitis as some cases can be caused by repeated lip licking, biting or chewing.5

Management of exfoliative cheilitis is difficult but it has responded to treatment with reassurance, topical steroids,6 psychotherapy and tranquillizers.7 Some cases can resolve spontaneously. Our patient's condition was resistant to emollients and life-style changes; only the very potent topical steroid Dermovate® helped, but relapse soon followed when it was stopped. Topical tacrolimus has successfully cleared the condition.

Tacrolimus is an immunomodulatory macrolide extracted from the fungus Streptomyces tsukubaenis.8 It is currently licensed for treatment of atopic dermatitis which is insufficiently responsive to ‘conventional therapies’.9 Tacrolimus ointment does not appear to impair collagen synthesis10 and is licensed for use on areas where skin is naturally thin such as the face, neck and flexures. As far as we are aware, this is the first time that topical tacrolimus has been reported to have been used successfully to treat exfoliative cheilitis.

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