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Re: Allergy root cause?
The Ronin Views: 14,412
Published: 14 years ago
This is a reply to # 1,110,650

Re: Allergy root cause?

I found the case:

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

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.

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