Case summary
A 4-year-old boy complained of dryness of lips for a 3-month duration. The dryness progressed to becoming scaly and painful, and lesions extended beyond the lip area. The condition was associated with peri-oral itchiness. The boy was observed to be licking his lips subconsciously a few times per minute. The lesions started with a habitual licking of the lips. There was no history of allergies or any recent intake of a new drug. There was also no history of atopy in the patient or his family.
Questions
What is the diagnosis?
What is the underlying cause?
State the differential diagnoses.
Outline the treatment.
Answers
- The most likely diagnosis is peri-oral dermatitis. In this case, it is due to the lip-licking habit. It is characterized by a burning sensation around the mouth. This 4-year-old boy was described as having dryness over the area. The skin may appear dry, bumpy or scaly.Similar lesions may appear around the eyes, nose or forehead, usually after the use of a topical steroid. The diagnosis is clinical, and no specific test is required.
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The underlying cause is repetitive or prolonged contact with saliva.1 Repeated licking may also occur with lip chewing, thumb sucking or excessive drooling. Wind instrument players may also experience lip licker's dermatitis.
A psychological disorder, such as compulsive lip licking, may cause lip-licking dermatitis. The temptation to repeatedly lick one's lips may result from continuous and persistent breathing through the mouth.
Whenever there is prolonged contact of saliva with the skin, maceration occurs, which subsequently removes the protective oils secreted by the skin's sebaceous glands.2 Other known triggers include bacterial or fungal infections, fluoridated toothpaste, rosacea, oral contraceptives, and sunscreen.
The differential diagnosis includes herpes labialis. A specific drug eruption that is secondary to an allergic reaction can manifest as peri-oral lesions as well.3 Other differential diagnoses are peri-orificial dermatitis, steroid-induced rosacea-like dermatitis, and allergic contact dermatitis.
Withdrawal of the triggering factors is the most important step. An identified medication can be stopped or replaced. Habitual lip licking should be treated with psychotherapy or behavior therapy. A lip emollient may prevent the patient from licking. Oral steroids for five to seven days along with elomet ointment can reduce the inflammation. Alternatively, a topical calcineurin inhibitor, such as pimecrolimus cream, can be used for mild to moderate steroid-induced perioral dermatitis in children older than 2 years old, adolescents and adults.4 Infected lesions, after confirmation with a skin culture test, should be treated with specific antimicrobials.
References
- 1.ICD11 Mortality and morbidity statistics. Irritant contact dermatitis due to saliva. [Sep 20;2018 ]. http//icdwhoint Retrieved.
- 2.Watt CJ, Hong HC. Dermacase Lip licker's dermatitis. Can Fam Physician. 2002;48(6):1051. [PMC free article] [PubMed] [Google Scholar]
- 3.Saniasiaya J, Mohamad I, Johan KB, Mohamad S, Mat Lazim N. Sore mouth tongue and throat. Brunei Int Med J. 2017;13(3):94. [Google Scholar]
- 4.Schwarz T, Kreiselmaier I, Bieber T, et al. A randomized double-blind vehicle-controlled study of 1% pimecrolimus cream in adult patients with perioral dermatitis. J Am Acad Dermatol. 2008;59(1):34–40. doi: 10.1016/j.jaad.2008.03.043. [DOI] [PubMed] [Google Scholar]