Introduction

Exfoliative cheilitis (EC) is an uncommon condition affecting the vermilion zone of the upper, lower, or both lips. EC is characterized by the persistent production and desquamation of thick scales of keratin and flaking of the vermillion border. When removed, these scales leave a normal appearing lip underneath. Although the precise etiology of EC remains unclear, factors such as stress, personality disturbances, or psychiatric conditions are associated with its onset (1, 2). This condition can reduce a patient’s quality of life by affecting esthetics and normal functions such as eating, speaking, and smiling (3). Some EC cases are related to chronic injury secondary to habits such as repetitive biting, picking, sucking or unconscious licking of the lips. The cases of EC shown to arise from chronic injury are termed factitious cheilitis (4). Although exfoliative cheilitis is a condition of unknown etiology, it may be related to excessive production and subsequent desquamation of thick scales of superficial keratin. The lack of specific treatment makes exfoliative cheilitis a chronic disease that profoundly affects a person's life.

Case report

A 19-year-old female presented to the Oral Medicine clinic, Faculty of Dentistry, Chulalongkorn University in Bangkok with a chief complaint of scaly and peeling lips. The lesions had persisted on her lips for more than 7 years. She had been treated with a topical steroid, Desoximetasone (Esperson ®), however, the lesions did not improve. In fact, the lesions were aggravated. When prednisolone 20 mg/day and antihistamine were administered by her physician, the lesions presented larger scales and delayed exfoliation (Figure 1). During examination, the scales were yellowish and the patient did not have any burning sensation or pain on palpation. The patient described her lips as dry and inflexible. The previous diagnosis of her lip lesions by her physician was contact dermatitis. Therefore, a patch test was done and the results were positive to toothpaste containing sodium lauryl sulfate (SLS). Subsequently, the patient changed her toothpaste and started using the toothpaste without SLS. Her scaly lesions were cleaned with hydrogen peroxide mouthwash 1% and glycerin borax was topically applied to the lesions three times a day. After three weeks of treatment, the lesions showed marked improvement (Figure 2). During one year of follow-up and treatment, her lesions gradually improved until her lips returned to a normal appearance (Figure 3). Thus, glycerin borax was proved to be effective in the treatment of EC without any side effects. Glycerin borax is safe, low cost, and simple to use in the treatment of refractory EC. Patients with a positive patch test reaction to this agent should avoid using SLS containing toothpaste. Treatment success depends on the successful management of refractory EC by eliminating the aforementioned contributing factors. It also depends on conservative treatment.

Figure 1 Yellowish dry scales on the lower and upper lips of a 19-year-old female patient with exfoliative cheilitis.

Figure 2 Three weeks after initiating treatment with hydrogen peroxide 1% and glycerin borax, the appearance of the lips of the patient was improved.

Figure 3 One year after treatment with hydrogen peroxide 1% and glycerin borax, the lesions showed marked improvement and complete remission

Discussion

Various EC treatments have been reported (5-8). Glycerin borax is an antiseptic and is used primarily in oral and dental applications. The treatment of EC is difficult due to its chronic nature. A previous report showed that this disease was successfully treated with topical tacrolimus (5). Interestingly, a single center study reported that the use of topical calcineurin inhibitors (tacrolimus and pimecrolimus) and moisturizing agents for managing EC resulted in clinical improvement with complete or partial remission of the lesions on both the upper and lower lips (6). However, the authors stated that it was difficult to determine whether the patients responded because of the anti-inflammatory effect of the ointment or because the ointment or moisturizing agents acted as emollients keeping the patients’ lips from getting dry. Also, they assumed that the agents applied to lesions protected the area from irritants. Besides, the authors made efforts to increase the patients' awareness about the unconscious habits, helping them to reduce trauma to the site.

Some researchers reported that EC could be managed with an antidepressant medication (7). A chronic dry scaly EC lesion that resulted in reduced esthetics was treated with a topical preparation of Calendula officinalis ointment 10% used ad libitum (8). In the present case, the initial treatment, by the patient’s physicians, with systemic steroids and topical steroids on the EC lesions was not effective. On the contrary, the lesions expanded and did not improve. Discontinuing the use of toothpaste containing SLS was recommended and the use of toothpaste without SLS was suggested. A randomized control trial compared the efficacy of a dentifrice without SLS to a dentifrice with SLS on gingivitis in young adults aged 18-34 years (9). The study showed that the toothpaste without SLS was as effective as a regular SLS dentifrice on gingival bleeding scores and plaque scores. It also showed that there was no significant difference in the incidence of gingival abrasion. Moreover, a recent report found that toothpaste containing SLS caused leukoedema and mucosal desquamation (10). The long-term use of a toothpaste containing SLS might contribute to epithelial desquamation on the lips, as shown in the present case. The toothpaste without SLS is recommended for an individual who had positive patch test reactions to this agent.

During the treatment of our patient, glycerin borax was applied to her lesions topically after the lesions had been cleaned with hydrogen peroxide (0.1%). The lesions showed gradual improvement during one year of treatment. Subsequently, the lesions showed complete remission and her lips returned to a normal appearance. Only a very mild scaly recurrence on her lips was observed during the follow-up and the lesions resolved after applying glycerin borax.

Based on our patient’s outcome, the application of glycerin borax and hydrogen peroxide mouthwash (1%) proved to be useful in alternative treatment of EC. Also, these agents proved to be equally effective in the treatment of refractory EC. These medications are low cost and without any side effects during long-term treatment and follow-up. In the present case, SLS may have been the precipitating factor for EC. When choosing toothpaste, avoiding SLS in toothpaste should be recommended to patients with positive patch test reactions to SLS during management of this lesion.