Some research notes

We shoud start keeping a list of things we have tried and things that
have worked.


HERE IS A LIST OF MY RESEARCH NOTES....
LOK AT THE ONES THAT THE DOCOTRS HAVE WRITTEN TO EACH OTHER.....








Topical tacrolimus may be effective in the treatment of oral and perineal Crohn's disease D H Cassona, M Eltumic, S Tomlinb, J A Walker-Smitha, S H Murcha a University Department of Paediatric Gastroenterology, Royal Free and University College School of Medicine, London, UK, b Department of Pharmacy, Royal Free and University College School of Medicine, London, UK, c Department of Paediatrics, Watford General Hospital, Hertfordshire, UK
Correspondence to: Dr S Murch, University Department of Paediatric Gastroenterology, Royal Free and University College School of Medicine, Royal Free Campus, Rowland Hill St, London NW3 2PF, UK Email: smurch@rfhsm.ac.uk Accepted for publication 25 November 1999

BACKGROUNDCrohn's disease of the mouth or perineum is more common in young people, and notably resistant to treatment. However, there is increasing evidence that topical therapy with tacrolimus (FK506) may be effective in skin diseases resistant to cyclosporin because of its high uptake in inflamed skin and subsequent reduction in keratinocyte chemokine production.
PATIENTS AND METHODSTacrolimus ointment was made up inhouse from the intravenous or oral formulation and suspended in appropriate vehicles for perioral or perianal administration at an initial concentration of 0.5 mg/g. This was administered open label to eight children (aged 5-18 years) with treatment resistant oral (three patients) and/or ulcerating perineal (six patients) Crohn's disease.
RESULTSMarked improvement was seen in 7/8 patients within six weeks and healing within 1-6 months. One child with gross perineal and colonic disease showed little response. Two of the responders showed rebound worsening when tacrolimus was stopped or the dosage reduced rapidly, and one of these eventually required proctectomy. Slower weaning of drug concentration has been successful in 6/8 patients, with four receiving intermittent treatment and two on regular reduced dosage (0.1-0.3 mg/g) with follow up times of six months to 3.5 years. Serum concentrations of tacrolimus were undetectable in all patients.
CONCLUSIONSTopical tacrolimus at low concentrations (0.5 mg/g) shows promise in the management of childhood perineal and oral Crohn's disease, with no evidence of significant systemic absorption. However, rapid weaning or abrupt cessation of therapy may cause rebound worsening of disease. Further controlled studies are required to assess the efficacy and safety of this treatment.


Keywords: Crohn's disease; tacrolimus; children
-----------------------------

Allergy: Recurrent lip swelling may be inherited


GABY ZAGURY, MD, of Montreal, Que., inquires: "What's the best way to manage recurrent idiopathic angioedema? Is it possible that a trauma could reproduce angioedema of the upper lip in a patient who's had this condition before?"
Angioedema may have immunologic or non-immunologic causes, and tests to confirm the etiology aren't always feasible. Outlining possible causes to the patient may allow him or her to recognize the triggers. ASA sensitivity is a frequent cause that the patient may overlook. Drugs are the cornerstone of therapy. A few weeks or months of antihistamines will do the trick in most cases. Effective medications include hydroxyzine (Atarax, Multipax), ketotifen (Zaditen), and cetirizine (Reactine, Zyrtec). Dosages may need to be at the highest tolerable level; occasionally, a combination of these drugs is the best bet. H2antagonists such as cimetidine (Tagamet) or ranitidine (Zantac) can be used in conjunction with the H1 antihistamines but these haven't been consistently effective. Low-dose antidepressants such as doxepin (Zonalon, Sinequan) which have H1 and H2 antagonist effects and inhibit mediators such as platelet activating factor may be tried if the antihistamines aren't helpful. In refractory cases, prednisone -- either as a short course or as low-dose alternate day therapy -- may be necessary. As for whether trauma can reproduce such lesions in the upper lip, the answer is yes. If this symptom keeps recurring, consider the possibility of a condition known as hereditary angioedema. This manifests as angioedema of any part of the body especially the upper lip, larynx and gastrointestinal tract. Hereditary angioedema is caused by abnormalities of the complement system and may be diagnosed by testing for lower than normal levels of certain components of the complement cascade such as a C4 or a C1 esterase inhibitor level. Since there are different forms of this condition, it would probably be a good idea to refer to a specialist who can help identify which type you're dealing with.


Medications
Antihistamines (e.g., Hydroxyzine for acute attacks)
Doxepin (an older antidepressant) helps with chronic (continuous) form
Calcium channel blockers
Terbutaline
Colchicine
Danazol


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--------------------------------------------------------------------------------

Seborrhoeic dermatitis (SD) is a recurrent, chronic inflammation of the skin that occurs on sebum rich areas such as the face, scalp and chest, characterised by red scaly lesions. The are many studies indicating that Malassezia yeasts play an important role in the aetiology of this condition, most of the evidence for which comes from demonstrated responsiveness to treatment with antifungal agents. Its aetiology, however, is far from being resolved. Some believe that it is the immune response of the skin to the Malassezia that is the cause of the disease. Traditional treatments of SD have been the use of keratolytic agents or corticosteroids. Since the discovery of ketoconazole, a considerable amount of research has been focused on determining the efficacy of various antifungal agents. This article reviews clinical trial data on treatment options available for SD.



----------------------



Stay away from apples,mangos oranges


.1% pimecrolimus ointment or tacrolimus are immunomodualotrs
recommened by Treatment of Oral diseases handbook
---------------------------------------------




Treatment of inflammatory and/or autoimmune dermatoses with thalidomide alone or in combination with other agents
--------------------------------




Chrons disease may be casued by a mycobacterium.





Most auto immunity including the Sjogren's Syndrome can be handled if a more direct approach is taken (since you are taking exercise which tends to consume more bicarbonates and citrates ) such as a simple 1/2 teaspoon of baking soda in 1/2 glass of water taken twice a day. A more effective remedy in reducing that is the 1/2 teaspoon of baking soda plus 1/4 teaspoon of citric acid (or one whole lime about 8 teaspoon freshly squeezed plus 1/2 teaspoon of baking soda taken twice a day in 1/2 glass of water). Vitamin D3 of at least 5,000-10,000 i.u. and magnesium citrate 250 mg for 5 days out a week (has more magnesium than the ionic one) is quite helpful. I have seen auto immunity to reduce in many cases whenever it's summer and more sun. Initially I suspect that certain auto immunity is caused by a yet unidentified mycobacterium or mycoplasma which manifests itself similar to a fungus since antifungal remedy such as borax has good response if taken only briefly such as a month's period or two. The dose for men if I happened to be taking it to kill the mycoplasma (it seems they need large than a woman) is about 1/4 teaspoon of borax mixed in one liter of drinking water taken throughout the day, but in this case, perhaps once a week is enough due to being a bit more sensitive. The serum calcium should be reduced and most alkalizing remedy is done about 5 days out of a week. The back pain might be the lack of magnesium as ionic magnesium is insufficient in amount, so magnesium citrate (or magnesium gluconate, magnesium orotate, magnesium malate, magnesium chloride) 250 mg should generally be sufficient often 5 days out of a week and I think the body should have sufficient levels after a month.
---------------------------


FUCIBET cream

Has anybody used Vioform Hydrocortisone? Its a cream that contains an antifungal\antibacterial\corticosteroid combination
(clioquinol\hydrocortisone), similar to vytone (iodoquinol\hydrocortisone). I used it a few weeks ago for a
few days (less than a week) and i noticed my lips were almost perfect. So far its the cream that has worked best for me.
Im thinking about using it for a longer period.




Contact dermatitis
Lipstick allergy
Excessive lip sucking
Excessive pen sucking
Eczema
Glucagonoma
Iron deficiency anemia
Riboflavin deficiency
Mouth overclosure


------------------------------------------





try zinc and evening primrose oil (like 6 tabs 1000mgs)
-----------------------------------
That's some interesting information about the possibility of Herpes Simplex being the root cause of this problem. I don't know if you've seen any posts by Neem, but you should check those out as well, they might strengthen your hypothesis. I say this because Neem advocated using Glycerin mixed with Folic Acid. I did some research today and found one patent site that claimed to use Folic Acid mixed with some sort of Antibiotic cream to treat Herpes Simplex lesions. This site said that when treated with Folic Acid and Triple Antibiotic Cream, herpes lesions took about 2 to 4 days to clear. Who knows the validity of the claims on this site, but as you well know, most of us are willing to try most anything that looks the least bit promising. I'll continue to research Herpes and hopefully we'll find something out soon. Here's a link to the site I talked about:

http://www.freepatentsonline.com/4393066.html


--------------------------------
Vitamin E 400 mg three times a day is effective for dry lips
-----------------------------------------


L-lysine @ 1000mg twice a day with a stress formula B-complex supplement (Stresstabs) once a day seems to have worked for me. The first time I stopped taking the lysine my lips started peeling again. This time I gradually reduced the dosage and my lips are still normal. I'm to the point now where I take 500mg every few days (when I think about it), same with the Stresstabs.

I used a product specifically for lip exfoliation to remove dry skin (or at least smooth the edges), followed by moisturizer and topped with a vaseline lip balm. I also found super-wet compresses helpful, especially when the corners of your mouth are tight and cracking.

All told, I took the lysine for nearly six months before I was able to lower the dose without relapsing. I'm not a habitual biter or picker. There are aspects of my case that suggest a viral infection. (pictures & details in an ealier post) I think I've kicked it, or at least driven it back into dormancy...

---------------------------------

Make this lip balm end the problem


STEP 1: Melt 1 tsp. shredded beeswax, 2 tsp. coconut oil, 1/2 tsp. vegetable oil and one vitamin E capsule, also empty and add the contents from a Folic Acid Capsule 800 mcg and heat just enough to disolve and blend by putting all the engredients in a pan, by heating pan in boiling water.
STEP 2: Add 2 drops of almond oil.
STEP 3: Add 1 tsp. honey.
STEP 4: Stir the mixture until cool.
STEP 5: Pour into a container and let set until completely cool.

Also consume one capsule of Folic Acid a day.

------------------------------------

Case studies have been done into other uses of infliximab, such as to treat skin diseases. Remicade (infliximab) has been approved for treating ankylosing spondylitis, Crohn's disease, fistulizing Crohn's disease, pediatric Crohn's disease, psoriatic arthritis, psoriasis, Rheumatoid Arthritis , and ulcerative colitis. Infliximab is also prescribed (out of indication) for the treatment of Behcet's disease.[13] and infusions of infliximab have been used successfully in the treatment of sciatica due to slipped discs.[14]
There have been numerous case reports of the efficacy of infliximab in various inflammatory skin conditions diseases; psoriasis, in which increased TNFα has been demonstrated, is the most recent indication.[15]
Psoriatic Arthritis (PsA), a chronic systemic inflammatory disorder characterized by the association of Arthritis and psoriasis, follows a heterogeneous and variable clinical course.







-------------------------------------------------

GI disease and skin eruption


http://gidiv.ucsf.edu/course/things/Boh.pdf

----------------------------------------------

http://books.google.com/books?id=GizTjKk_9-kC&pg=PA260&lpg=PA260&dq=vermillio...





cheilitis is inflamation of the lips.
Causes:

regioinal enteritis
acrodermatis enteropathica (inherited inability to absorb sufficient amount of zinc from diet)
Alcoholism
pyridoxine deficiency
riboflavin defficiency
folate deficiency
sprue
kwashiokor
viral illness
oral candidiasis
hypervitaminosis A
actinic prurigo
iron deficiency anemia with or without Plummer-Vinson syndrome


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Things that cause EX CHELIITS

myobacterium-leprosy type use lamprene
abnormal thyroid function
Candiasis



Cutaneous Crohn's disease mimicking Melkersson-Rosenthal syndrome: treatment with methotrexate
V Tonkovic-Capin, SS Galbraith
Abstract
A woman with a 5-year history of unilateral orofacial granulomatosis required repeated evaluations (including sequential colonoscopies) to establish the diagnosis of cutaneous Crohn's disease, a condition that proved responsive to low doses of ...

Journal of the European Academy of Dermatology and
---------------------------


Spirochetes--the possible etiological factor of the cheilitis granulomatosa.
Abstract OBJECTIVE: To detect spirochetes in sections and to study the therapeutic effect of penicillin in cheilitis granulomatosa (CG) and Melkersson-Rosenthal syndrome (MRS) and the relationship between the spirochetes infection and CG and MRS. METHODS: Routine HE sections and Warthin-Starry special staining were carried out in 20 cases of CG and 6 cases of MRS. Meanwhile there were 9 cases of CG and 2 caes of MRS were treated by penicillin (12 000 000u, i.v., per day) for two courses (14 days). RESULTS: A kind of spirochete was discovered in the sections of all cases of the CG and MRS. The CG and MRS could be divided into two types histopathologically, that is granuloma type and interstitial inflammatory type (non-granuloma type), those morphological changes tallied with spirochetosis. After treatment by penicillin, the facial and labial swelling of the 11 cases of CG and MRS were abated. CONCLUSION: CG and MRS probably are infectious diseases caused by spirochetes.



Elidel
I have chronic peeling lips (used to be a biter), and I gave Protopic a brief

try last year with very unpleasant results. It actually made my lips peel more

during the two weeks I used it, and it made me break out around my mouth. I

have had better luck with Elidel as far as prescription creams go. It doesn't make

the peeling stop, but it definitely slows it down


topical tacrolimus
acrolimus 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

Niacin deficiency
Thank you for the invaluable site.
To make a 30yr long story short, which reads almost verbatim to all of yours, I accidentally discovered that taking 1.5 GRAMS (500mg 3x daily) of standard Niacin for 3 weeks causes my lips to completely heal, and my skin on my face to become baby soft and very supple.
Unfortunatley, if I stop, after 2 days my lips and skin go back to being screwed up as ever. I am convinced that for some reason my body is not absorbing vitamins as it should, so I was taking the Niacin to improve my production of stomach acid and grow more cilli...
Do not use the flush-free niacin, as its usage is linked to liver damage.


miconazol gel 25 mg
Cured patients that had fungus releated cheilitis



----------------------------------------------------------------
Chelitis granulamatosa

A 39-year-old woman presented with a 5-month history
of painless, nonitching swelling of the upper lip
(Figure 1). In addition, she had a symptomless lingua
plicata. A biopsy specimen revealed cheilitis with
edema and perivascular lymphohistiocytic infiltrates
(Figure 2) pointing to an early stage of cheilitis granulomatosa
(CG). There was no neurologic abnormality
such as facial palsy. Also, there were no findings or history
of previous infection or local contact allergy. Systemic
clofazimine therapy was started at 200 mg/d but
discontinued after 2 weeks because of a morbilliform
eruption. Over the following 4 months, dapsone
therapy at 50 mg/d had no effect. Thereafter, prednisone
treatment at 40 mg/d for 10 days reduced the lip
swelling but was followed by an immediate recurrence
on discontinuing the treatment.
THERAPEUTIC CHALLENGE
Cheilitis granulomatosa by itself or as part of the Melkersson-
Rosenthal syndrome is characterized by a chronic
course. In our patient this could not be controlled by clofazimine,
dapsone, or prednisone. Another therapeutic
option was needed.
SOLUTION
Since tumor necrosis factor alpha (TNF-
) is a key chemokine
in most types of acute and chronic inflammation,
1,2 thalidomide was considered as an alternative
therapeutic approach. Treatment consisting of 100-
mg/d oral thalidomide was initiated. Over the next 6
months, the lip swelling almost completely disappeared
(Figure 3). Thalidomide treatment was then reduced
to 100 mg every other day for 2 months, and no recurrence
was observed. Therapy was then stopped. One
year after discontinuation of the therapy, the patient's
condition was still stable without any signs of a
relapse.
In view of the potential adverse effects, most notably
teratogenicity and peripheral neuropathy, absence of
pregnancy, effective contraception, and a normal neurological
status were ascertained prior to treatment. Routine
laboratory parameters including red and white
blood cell counts and liver transaminase levels, neurologic
status, and clinical findings were regularly monitored
during administration of thalidomide. The treat-
Figure 1. Patient with edematous enlargement of the upper lip.
Figure 2. Disseminated foci of cellular inflammation with tissue edema.
THE CUTTING EDGE
(REPRINTED) ARCH DERMATOL/VOL 139, FEB 2003
http://WWW.ARCHDERMATOL.COM

136
©2003 American Medical Association. All rights reserved.
Downloaded from
http://www.archdermatol.com
on January 26, 2008
ment induced neither pathologic alterations of laboratory
findings nor neuropathy. The only adverse effect noted
was some morning tiredness.



-----------------------------------------------------------------------------------
Hey all. This is an incomplete meta-list that I've compiled. Showing this to the derm might be helpful and indicative of the seriousness/difficulty in dealing with whatever is happening with our lips. Also, I will give somebody a giant gold bar if they can prove to me that our condition is factitious; claiming that whatever is happening is due to psychological problems might actually cause me to go insane.. :(

Here is a webpage that may provide some useful info (basically, it's a bunch of doctors talking about EC; you must type "exfoliative cheilitis" into the search field):
http://listserv.buffalo.edu/cgi-bin/wa?S1=BBOPLIST



CASE 1 - Anonymous from Web
HISTORY AND SYMPTOMS
***41 year old female, lip dryness/peeling/soreness, episodes of bleeding, admitted to lip picking, symptoms persisted for 8 months
***No history of atopic dermatitis
EXAMINATION
***Had dry lips, scaling, crusting, particularly involving the vermilion border
***A diagnosis of exfoliative cheilitis was made
***Tests revealed a normal full blood count, serum ferritin on the lower side of normal (17 μg I 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 flavorings series, as well as the patients own toothpaste and moisturizer.
TREATMENT
***Hydrocortisone cream, fucidin cream (fusidic acid 2%, hydrocortisone acetate 1%), fucibet cream (fusidic acid 2%, betamethasone 0*1%), daktacort cream (hydrocortisone 1%, miconazole nitrate 2%), metrogel (metronidazole 0*75%), eumovate cream (clobetasone butyrate), blistex, soft white paraffin, iron supplementation failed.
***The patient made a conscious effort not to pick or rub her lips.
***Dermovate ointment (clobetasol propionate 0*05%) was used sparingly twice daily for 3 weeks. This alleviated symptoms, but the cheilitis recurred upon stopping treatment.
***Topical tacrolimus Protopic ointment(0*1%) used twice daily. Within 4 weeks, the cheilitis had cleared. Due to the excellent response, the tacrolimus therapy was reduced to once daily for a few additional weeks and then to alternate days. The patient now remains symptoms free by using tacrolimus only why symptoms flare. No adverse effects from tacrolimus were reported
REFERENCES
***http://drugtalk.com/metronidazole/drugthread.php/t-122721.html

CASE 2 - Eedbeedee from curezone
HISTORY AND SYPTOMS
***Has had exfoliative cheilitis symptoms for 9 years
***Thought the lip problem might have a bowel involvement function
Examination
***Had a comprehensive stool analysis with parasitology. The person reported that the test revealed a severe bacterial infection at the extreme end of the scale. The bacteria was identified as Staph aureus. The stool had a pH of 5.2 (normal is between 6-7.2), there were triglycerides present. Tested negative for celiac (gluten) disease, mild chronic gastritis, negative for intestinal inflammatory markers.
TREATMENT
***Not discussed
REFERENCES
***Screen name: Eedbeedee
***//www.curezone.org/forums/m.asp?f=403&i=594#i

CASE 3 - Cureforcurezone from curezone
HISTORY AND SYMPTOMS
EXAMINATION
TREATMENT
***Didn't work:
******Prevex, Betaderm, Retin-A, Elidel (pimecrolimus), surgical removal, laser lip peels
***Showed responses
******Protopic burned a lot (tacrolimus; in a class of calcineurin inhibitors).
******Fucidin stopped the peeling, but became immune after 6 months of use. Now uses for special occasions.
******Efudex made worse; restarted peeling in areas that had previously stopped.
******CO2 laser shave may have healed a small area.
******Biopsy showed no fungus and only chronic irritation.
REFERENCES
***Screen name: Cureforcurezone

CASE 4 - Person from curezone
***Reported that multiple N-lite laser sessions, performed by Dr. Anthony Chu at Hammersmith Private Hosptial (Hammersmith, London) may have healed condition.

CASE 5 - Haughey99 from curezone
HISTORY AND SYMPTOMS
***Drinking beer made lips worse the next day.
Examination
***Biopsy tested positive for yeast.
Treatment
***Propolis, Zoloft (50 mg for 3 months), Ketoconazole, hydrocortisone creams, nysatin, and diflucan didn't work.
***Prednisone helped for a little while but eventually made much worse.
***Lamprene, prescribed by Dr. James Sciubba of Johns Hopkins, reportedly cleared the condition.
REFERENCES
***Screen name: Haughey99

CASE 6 - Alesiom11
HISTORY AND SYMPTOMS
***Bit lips when younger.
***Has reported a continual cycle of lip crusting and white material on the upper gums.
EXAMINATION
***Biopsy revealed a.paraphrasing "malpighian epithelium with a clearly hyperplastic, and partly ulcerated covering. There was a lateral erosion of the superficial layer. On top, there was a significant amount of fibrin with remainders of polymorphonuclear leucocytes. A moderating polymorphous exocytosis was clearly visible as were multiple micro-abscesses. The underlying connective tissue contains superficial and sparse polymorphous inflammatory infiltrates with PMN (neutrophile) leucocytes." Biopsy was done of the upper lip, with half of the area consisting of mucus membrane material.
***There was a negative PAS. See comments below in thoughts and ideas.
***Lab concluded that there was a.paraphrasing "benign epithelial hyperplasia with an inflammatory background, which was caused by a reaction."
TREATMENT
REFERENCES
***Screen name: Alesiom11 @ curezone

CASE 7 - Anonymous from Web
***A person who might or might not have had exfoliative cheilitis was reportedly cured after being prescribed Benadryl


THOUGHTS AND IDEAS
GENERAL
***Clofazimine 300 mg/day
******May suppress t-cell function in chronic graft versus host disease (cGVHD).
******Clofazimine inhibition of the myeloperoxidase system may be responsible for its anti-inflammatory effects.
***Collagen overgrowth can be treated with Kenalog or 5FU injection.
***The presence of micro-abscesses and a negative PAS (as seen with Alesiom11's biopsy) might warrant testing for acid-fast bacilli.

POTENTIOAL AND/OR RELATED CONDITIONS
***Cheilitis Glandularis (Cheilitis granulomatosa of Miescher/Meischer's Cheilitis, monosymptomatic Melkersson-Rosenthal syndrome)
***Crohn's disease
***Sarcoidosis (serum angiotensin-converting enzyme test can be performed to help exclude this condition)
***Cultured Strep.agalactiae in tests
***Thyroid function
***Keratosis pilaris
***Lupus pernio
***Myxedema
***Whipple's disease
***Mycobacterium Marinum cutaneous infection
***Malassezia Fungus
***Folliculitis
***Mollusium
***HPV
***Seborrheic Keratosis
***Macrocytosis
***Pretibial myxedema (a rare complication of Grave's disease)


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Fucibet cream
Quadriderm NF

Date: Thu, 31 Mar 2005 13:45:58 -0400
Reply-To: Bulletin Board of Oral Pathology <[log in to unmask]>
Sender: Bulletin Board of Oral Pathology <[log in to unmask]>
From: "DR. BENJAMIN MARTINEZ" <[log in to unmask]>
Subject: Re: exfoliative cheilitis therapy
In-Reply-To: <[log in to unmask]>
Content-Type: text/plain; charset="us-ascii"; format=flowed
Some patients have "juvenile juxtavermilion candidosis". Treatment:
two-four weeks with antimycotic.
References:
Reade P et al. Cheilo-candidosis. Brit.Dental J. 152:305, 1982.
Bouquout JE et al. JADA 116: 187, 1988.
Samaranayake LP. and Mac Farlane T. Oral Candidosis ("The bible of
candidosis"). Wriight, London, see page131 and plate 12 (I have seen more
severe cases than this one).
Best regards,
Dr. B Martinez
-----------------------------
Date: Mon, 28 Feb 2005 16:25:41 +0100
Reply-To: Bulletin Board of Oral Pathology <[log in to unmask]>
Sender: Bulletin Board of Oral Pathology <[log in to unmask]>
From: Giuseppe Ficarra <[log in to unmask]>
Subject: Re: exfoliative cheilitis therapy
Content-type: text/plain; format=flowed; charset=iso-8859-1; reply-type=original
Dear Tom:
you may want to try topical tacrolimus.
Reference:
Connolly & Kennedy
Exfoliative cheilitis succesfully treated with topical tacrolimus.
Br J Dermatol 2004; 151:232
Regards
Giuseppe Ficarra
Reference Center for the
Study of Oral Diseases
Florence, Italy
-------------------------------------
Date: Mon, 28 Feb 2005 12:50:18 -0500
Reply-To: Bulletin Board of Oral Pathology <[log in to unmask]>
Sender: Bulletin Board of Oral Pathology <[log in to unmask]>
From: "Dwight R. Weathers" <[log in to unmask]>
Subject: Re: exfoliative cheilitis therapy
Content-Type: text/plain; charset=us-ascii
Dr. Daley,
I would consider the posibility of a hypersensitivity reaction. If you can
find the source, and it is removed, he will "cure" himself. I had a young
girl years ago with a similar presentation, who used to touch a majic
marker to her tongue and lips to paint with. She responded as +++ to a
skin test with the material. When this practic was discontinued, her lips
became normal. It may require a lot of delving into the patients history
and it is likely to be long and difficult before you find the offending
substance.
Ronnie Weathers
--------------------------------------
Date: Mon, 28 Feb 2005 12:09:47 -0500
Reply-To: Bulletin Board of Oral Pathology <[log in to unmask]>
Sender: Bulletin Board of Oral Pathology <[log in to unmask]>
From: "Nour N. Masud" <[log in to unmask]>
Subject: Re: exfoliative cheilitis therapy
Content-Type: text/plain
I had a patient presented with a history of exfoliated cheilitis for
years, he claimed he tried anti fungals, Vaseline, and few other
topicals. We recommended trying cleaning the area with warm water few
times a day; he is getting much better. Oral surgery, suggested
antimicrobial creams, he did not have to use them yet
Try some of the following papers,

Leyland L, Field EA. Exfoliative cheilitis managed with antidepressant
medication.Dent Update. 2004 Nov;31(9):524-
6. 2004 Nov;31(9):524-6.
ExConnolly M, Kennedy C.foliative cheilitis successfully treated with
topical tacrolimus.
Br J Dermatol. 2004 Jul;151(1):241-2.

Casariego Z, Pombo T, Perez H, Patterson P.Eruptive cheilitis: a new
adverse effect in reactive HIV-positive patients subjected to high
activity antiretroviral therapy (HAART). Presentation of six clinical
cases.Med Oral. 2001 Jan-Feb;6(1):19-30.
Daley TD, Gupta AK.Exfoliative cheilitis.
J Oral Pathol Med. 1995 Apr;24(4):177-9.
Nour Musa
SUNY at Buffalo
-------------------------------------------------
Date: Mon, 28 Feb 2005 11:06:44 -0500
Reply-To: [log in to unmask]
Sender: Bulletin Board of Oral Pathology <[log in to unmask]>
From: "Dr. Michael A. Siegel" <[log in to unmask]>
Subject: Re: exfoliative cheilitis therapy
In-Reply-To: <[log in to unmask]>
Content-Type: text/plain; charset="iso-8859-1"
Tom:
I had one very severe case. It turned out that the exfoliative cheilitis
was secondary to angioedema from seafood. This caused her lips to evert,
exposed the mucosal surface and the exfoliation started from there. This
women had suffered for six months and actually postponed her wedding.
I placed her on 25 mg qid of diphenhydramine for two weeks, had her stand in
a hot shower and gently debride her lips and used an emollient to keep them
moist. I then ran a C1 esterase inhibitor to rule out hereditary angioedema
(which was not surprisingly negative) and got her to d/c shellfish. Start
by ruling out angioedema with the normal causative etiologies.
I hope this helps.
Mike

----------------------------------------
Hello Again Dr. Collins:
You raise several good points. I would not necessarily consider a trial
with betamethasone valerate ointment 0.1% unless the diagnostic criteria
for burning lips syndrome/sialadenitis were demontrated (lack of function
of minor sailvary glands, histologic appearance consistent (chronic inflam
infiltrate, insipated mucin, etc)) were demonstrated. Yes! This topical
approach could show efficacy even with a prior history of failure with
injectable steroids. But it is possible that the patient may be having an
allergic reaction to PABA within the chap stick and your idea of removing
the chap stick may be helpful. PABA is a relatively common allergen.
Best wishes,
Ron Brown
On Wed, 10 Nov 1999, Bobby Collins wrote:
> Hello Dr. Brown,
> When you first look at this patient, the lip appearance is normal, but
> after just a few minutes of talking, the lips look a bit cyanotic. At the
> wet-dry line, a brownish-tan crust (like dried apple jelly) develops. I
> thought the minor glands were crowded out by abundant Fordyce granules in
> the upper lip. He seems to have a lot of Fordyce spots. One of the
> dermatologists thought that sebum was the culprit and I just don't know.
> Would betamethasone be of benefit if steroid injections and Vytone therapy
> failed?
> A respected colleague told me that they had seen exfoliative cheilitis
> associated with Chapstick usage. I told my patient to cease the Chapstick
> and I believe he will.
> Thanks,
> Bobby
>
--------------------------------
Date: Fri, 16 Jul 1999 15:21:31 +0100
Reply-To: Bulletin Board of Oral Pathology
<[log in to unmask]>
Sender: Bulletin Board of Oral Pathology
<[log in to unmask]>
From: Newell W Johnson <[log in to unmask]>
Subject: Re: Exfoliative Cheilitis
Content-Type: text/plain; charset="iso-8859-1"
Thank you to Michael Seigel, Cris and other colleagues for their helpful
comments.
If I achieve anything I will let you know.
Newell
At 09:15 16/07/99 -0400, Michael A. Siegel wrote:
>Good morning from Baltimore:
>
>This is in response to a query from Dr. Newell Johnson about the
>management of exfoliative cheilitis. I did not notice your initial
>request for information regarding exfoliative cheilitis posted a few
>months ago to the BBOP. Sorry!
>
>From the outset, let me qualify my comments by letting you know that I
>have only managed one case of this disorder. To my knowledge, it is
>quite rare and as Professor Scully eloquently pointed out yesterday, is
>multi-factorial in etiology and is often refractory to therapy only to
>resolve spontaneously for no known reason. I have documented this case
>in terms of clinical photographs and histology, but have been reluctant
>to publish it because I am not sure whether my management actually "gave
>this patient back her life" or if she resolved spontaneously in spite of
>my efforts. If my management of this patient is also successful in
>yours, please contact me as I would be honored to publish this paper
>with you.
>
>This patient is a 32 year old white, otherwise healthy female who
>acquired her cheilitis 3 months prior while participating (with her
>fiancée) on a three week wilderness hike in the U.S. Pacific Northwest.
>She initially thought that her cheilitis was related to drinking stream
>water or eating wild berries. She was seen by a number of prominent
>dentists and physicians who established this diagnosis and performed a
>number of tests and employed a number of therapeutic medication trials
>without result. She was ANA, RF, ESR and Lyme titer negative. CBC,
>differential and SMAC were normal, as well. The medication trials
>included topical and systemic antifungal medications, steroids and
> Antibiotics . Biopsy was essentially negative. The superficial crusts
>were suggestive of calculus with scanty bacteria present. There was
>minimal, if any mucosal inflammatory infiltrate, no mast cells, and the
>acini were completely normal suggesting against cheilitis glandularis,
>granulomatosa or the Melkerson-Rosenthal syndrome. The patient was
>quite upset over her appearance, but denied any sleep disturbance or
>previous psychiatric history. The literature review was consistent with
>Professor Scully's posting yesterday. It seemed that all of the
>available therapeutic modalities had been exhausted.
>
>In examining this patient, what initially struck me was the size and
>thickness of the plaques covering her upper and lower lips. There was
>no question in my mind why she cancelled her wedding. The psychosocial
>implications of this disorder became immediately obvious. What puzzled
>me was that the plaques extended from the squamous edge of the vermilion
>border to within 1.0 cm of her vestibular fornices. I considered the
>fact that her lips must have been everted so as to account for the
>mucosal coverage of her plaques.
>
>When I questioned her with regard to atopy, she claimed that she had
>multiple allergies as a child and continued to react to both MSG
>(monosodium glutamate) and strawberries; she skin tested positively for
>both of these food stuffs. I chose to treat her for angioedema in an
>effort to resolve her everted lips thereby resolving the air-exposure.
>Admittedly, the histology did not strikingly suggest this disorder. I
>procured a C-1 esterase inhibitor which was normal both quantitatively
>and qualitatively thereby ruling out the hereditary form of this
>disorder.
>
>I offered the patient the following treatment:
>
>1. I prescribed Benadryl (diphenhydramine) 25 mg after each meal and
>50 mg at bedtime. The H-1 receptor antagonists such as terfenadine and
>astemazole were available at the time, but I thought the sedative effect
>of the Benadryl would be beneficial to this patient due to her
>frustration and to quell any secondary habit she had likely acquired.
>
>2. I told her to take hot showers and to "peel off" as much of the
>crust as she could from her lips.
>
>3. I told her to use an emollient ointment to keep her lips covered
>from exposure to the air. I used Oral Balance (LaClede Laboratories)
>for this patient. This gel contains a lactoperoxidase and is quite
>helpful as an oral lubricant. Today, I would use a product such as
>Aquaphor, an emollient healing cream favored by some of my dermatology
>colleagues (petrolatum and lanolin preparation). I am sure that a
>petrolatum product would serve this purpose well.
>
>Within 48 hours, this patient called me crying on the telephone and
>claimed that her lips were starting to "feel normal again." I had her
>remain on the Benadryl for a three week period and reappointed her for a
>follow-up evaluation during the fourth week. Her cheilitis had
>completely resolved and has not recurred since that time. The wedding
>was lovely!!!! As a state employee, my mantra is, "never turn down a
>free meal."
>
>Obviously, I was quite gratified at the results of this conservative
>care. The patient was exuberant, which always makes practice fun.
>However, I remained skeptical of taking credit for her resolution
>because, as mentioned above, the response may have been entirely
>coincidental. Having only managed one case of this disorder, to this
>day, I do not know if this presentation is representative of the other
>cases out there.
>
>Please let me know if this case description is helpful to you and your
>patient. If my suggestions help your patient, I am quite sincere about
>a joint publication of our findings.
>
>With regards,
>
>Michael
>
>Michael A. Siegel, DDS, MS
>Associate Professor of Oral Medicine
>Associate Professor of Dermatology
>University of Maryland, Baltimore
>666 West Baltimore Street
>Baltimore, Maryland 21201-1586
>Telephone: 410-706-7628
>
>
----------------------------------------
Date: Thu, 15 Jul 1999 21:10:16 +0100
Reply-To: Bulletin Board of Oral Pathology
<[log in to unmask]>
Sender: Bulletin Board of Oral Pathology
<[log in to unmask]>
From: Crispian Scully <[log in to unmask]>
Subject: Exfoliative cheilitis
Comments: To: [log in to unmask]
Content-Type: text/enriched; charset="iso-8859-1"
Newell; maybe this is of some help
From
Scully C, Bagan J, Eisen D, Porter S, Rogers NR.
Dermatology of the Lips
Isis Medical Publishers, Oxford. 1999 (in press)

Exfoliative cheilitis (factitious cheilitis, le tic de lèvres)
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).

Professor Crispian Scully
MD, PhD, MDS, FDSRCS, FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci
Dean, Director of Studies and Research
International Centres for Excellence in Dentistry, and
Eastman Dental Institute for Oral Health Care Sciences
University of London
256 Gray's Inn Road
LONDON WC1X 8LD
UK
Tel; 441719151038
Fax; 441719151039
Eastman website;
http://www.eastman.ucl.ac.uk

Personal website;
http://www.eastman.ucl.ac.uk/~cscully/

This email may contain confidential information and may be
protected by law as a legally privileged document and copyright work.Its
content should not be disclosed and it should not be given or copied to
anyone other than the person(s) named or referenced above. If you have
received this email in error, please contact the sender.
--------------------------------
Date: Mon, 8 Feb 1999 16:47:51 EST
Reply-To: Bulletin Board of Oral Pathology
<[log in to unmask]>
Sender: Bulletin Board of Oral Pathology
<[log in to unmask]>
From: Paul Freedman <[log in to unmask]>
Subject: Re: Help - desquamative cheilitis
Content-type: text/plain; charset=US-ASCII
I have always found Vytone cream (hydrocortisone & iodoquinol), rub into lips
qid, a very effective way to treat exfoliative cheilitis .
Paul Freedman
-------------------------------------
Dear Prof. Johnson:
In Mexico, like in all other Latin-American countries with Mestizo
populations Actinic Prurigo is one of the main causes of cheilitis, but
this idiopathic photodermatosis has some clinical, immunogenetics, and
microscopic features that helps to separate from other causes of lip
diseases. Most cases appear in chilhood (6-8 years), there is a marked
predominance in women (2 to 4:1), affects mainly skin types IV to V and has
an exellent response to thalidomide. I recommend the following review
paper:
Hojyo-Tomoka T et al, Actinic Prurigo: An Update. Int J
Dermatol1995;34:380-4.
I have been working with Dra. Hojyo Tomoka and her team for more than seven
years, and during that period we have seen more than 120 cases of AP and
only two cases of what we consider exfoliative cheilitis, which were
unrelated to retinoids or any other medications.
Regards, A. Mosqueda Taylor
Departamento de Atención a la Salud
Universidad Autónoma Metropolitana-Xochimilco
Mexico, D.F.

-------------------------------------------
Date: Mon, 17 Nov 1997 16:56:45 -0500
Reply-To: Bulletin Board of Oral Pathology
<[log in to unmask]>
Sender: Bulletin Board of Oral Pathology
<[log in to unmask]>
From: "Douglas D. Damm" <[log in to unmask]>
Subject: Re: CRUSTED LIPS
In-Reply-To: <[log in to unmask]>
Content-Type: text/plain; charset="us-ascii"
At 12:39 PM 11/17/97 -0500, you wrote:
>Dear Bbopers,
>A 19 year white male present brown crusts/scabs of the upper and
>lower lips completely on vermillion that covered approximately 15% total
>lip area. They appeared to be vertical and followed the fissures in lip.
Dear John & BBOPers,
Ronnie is correct in suggesting a hypersensitivity reaction, but many
cases of exfoliative cheilitis have arisen from secondary infection in
areas of previous damage (such as badly chapped lips or areas of factitious
injury). In these cases, the majority are infested with candida
(cheilocandidiasis) and a few with staph or strep.
In the past, old Mycolog worked well with its steroid, antifungal and
antibacterial. With the loss of Mycolog, Vytone would be one of my first
choices if the patient can live with the Iodine taste. If review of the
patient's history reveals no use of Accutane or contact with an allergen,
Vytone may be your next step.
Doug
.
Douglas D. Damm
Oral Pathology
College of Dentistry
University of Kentucky
Lexington, KY, USA 40536-0084
E-Mail: [log in to unmask]
Phone: (606)323-5515
Fax: (606)323-2525
------------------------------------------------------------
Dear Bill,
Obese patients get Candidiasis in their (sweatty) fat folds & people who
wear rubber boots or other rubber-soled footwear get "athlete's foot" -
why, because skin is normally dry. Constant moistening of skin "macerates"
(softens & breaks down) the outer keratin barrier to microorganisms (mixed
oral / skin flora), which thus overgrow, stimulating, in the case of
Candida, epithelial proliferation (pseudoepitheliomatous hyperplasia), as
well as an inflammatory / immunologic response. This at least partially
explains "chapped lips", exfoliative cheilitis and angular cheilosis.
Cheers,
John.
Dr. John G.L. Lovas
Div. of Oral & Maxillofacial Pathology
Faculty of Dentistry
Dalhousie University
5981 University Avenue
Halifax NS CANADA B3H 3J5
Phone: (902) 494-1413
Fax: (902) 494-2527
E-mail: [log in to unmask]
----------------------------------------------------
Date: Thu, 10 Oct 1996 21:22:59 -0500
Reply-To: Bulletin Board of Oral Pathology <[log in to unmask]>
Sender: Bulletin Board of Oral Pathology <[log in to unmask]>
From: DR PAUL D FREEDMAN <[log in to unmask]>
Subject: Re: VYTONE?
Dear Dr. Aydin:

The ingredient in Vytone that deals with the candida infection
in angular cheilitis is the iodoquinol. The steroid has an anti-
inflammatory effect that also deals with any potential topical
reaction to the iodoquinol. We have also used Lotrisone which has a
steroid with clotrimazole. If we use clotrimazole (Lotrimin) alone,
we often get an exfoliative cheilitis, probably as a topical
reaction to the Lotrimin. The addition of the steroid prevents that
problem.

Paul Freedman

-------------------------------------------------
Date: Thu, 10 Oct 1996 21:22:59 -0500
Reply-To: Bulletin Board of Oral Pathology <[log in to unmask]>
Sender: Bulletin Board of Oral Pathology <[log in to unmask]>
From: DR PAUL D FREEDMAN <[log in to unmask]>
Subject: Re: VYTONE?
Dear Dr. Aydin:

The ingredient in Vytone that deals with the candida infection
in angular cheilitis is the iodoquinol. The steroid has an anti-
inflammatory effect that also deals with any potential topical
reaction to the iodoquinol. We have also used Lotrisone which has a
steroid with clotrimazole. If we use clotrimazole (Lotrimin) alone,
we often get an exfoliative cheilitis, probably as a topical
reaction to the Lotrimin. The addition of the steroid prevents that
problem.

Paul Freedman
----------------------------------------------
Date: Mon, 1 Jul 1996 22:34:59 -0400
Reply-To: James Sciubba MD <[log in to unmask]>
Sender: Bulletin Board of Oral Pathology <[log in to unmask]>
From: James Sciubba MD <[log in to unmask]>
Subject: Re: Exfoliative cheilitis
Comments: cc: John Lovas <[log in to unmask]>
In-Reply-To:
Dear John:
We have seen what I believe you are describing. Our philosophy has been
to consider this as a fungal infection, and therefore agree with John
McDonald. In addition to withdrawing toothpaste, etc as you have done, I
would aggressively treat as a fungal process for 5 days with fluconazole
at 100 mg daily in addition to topical agents (light ointment or cream
vehicle). In addition I would recommend that you address the lip licking
habit which this lady has. I would venture that there is a perioral
reaction with erythema and some effacement of the labial/vermilion
junction.
This may also be seen in HIV patients and the debilitated.
Good Luck -- I'd like to know how your patient fares.
Regards, Jim Sciubba

This
message represents the personal views and opinions of
the individual sender and should in no way be construed as an authorized
communication on behalf of Long Island Jewish Medical Center.
-------------------------------------------------
Date: Mon, 1 Jul 1996 22:19:27 -0400
Reply-To: Bulletin Board of Oral Pathology <[log in to unmask]>
Sender: Bulletin Board of Oral Pathology <[log in to unmask]>
From: James Sciubba MD <[log in to unmask]>
Subject: Re: Exfoliative cheilitis
Comments: cc: John Lovas <[log in to unmask]>
In-Reply-To:
John: I agree with John McDonald. Our experience shows good results in
treating exfoliative cheilitis by eliminating fungi, withdrawing use of
topical occlusives such as Vaseline and eliminating any factitious
influences such as lip licking. I would be surprised if your patient
doesn't have a degree of perioral erythema or fissuring as a result of
this possible fungal infection.
Good Luck - Jim Sciubba

This message represents the personal views and opinions of the
individual sender and should in no way be construed as an authorized
communication on behalf of Long Island Jewish Medical Center.

------------------------------------------------------

 

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