Angular cheilitis-an oral disease with many facets.

Cheilitis is a common inflammatory disorder of the vermillion and adjacent skin of the lips. A special type is angular cheilitis. The disease has a mixed etiology, mostly with bacterial and fungal components. Angular cheilitis may be a clinical sign of an underlying disease. It has two age peaks: one during childhood and another in adults. It becomes more frequent with aging. Clinical presentation, differential diagnoses, and treatment are discussed. Angular cheilitis is of importance in primary care of patients, in geriatrics, dentistry, pediatrics, internal medicine, and in dermatology.

Cheilitis: A cross-sectional study-multiple factors involved in the aetiology and clinical features.

OBJECTIVE: Since the aetiologies of cheilitis are broad and overlapping, the purpose of this cross-sectional clinical study was to examine the multiple factors involved in aetiology and the disease's clinical features. SUBJECTS AND METHODS: We analysed cheilitis prevalence, demography, clinical features, patients' habits, psychological stress, systemic diseases, vitamin B9, B12 and iron serum levels and allergy test results in a total of 130 subjects with cheilitis, plus 22 healthy subjects. RESULTS: The most common cheilitis types were: cheilitis simplex and eczematous cheilitis (28.5%); herpetic cheilitis (16.9%); and exfoliative and angular cheilitis (7.7%). Concerning bad habits, there was a significant association/connection between self-reported saliva at the corners of the mouth and angular cheilitis, and between lip licking/biting and exfoliative cheilitis. Common associated conditions were skin diseases (56.5%) and atopy (84%). Vitamin B9 and B12 serum and iron values were mostly within the normal reference range. The patients suffering from herpetic cheilitis had significantly higher psychological/mental stress levels than the control group. CONCLUSION: To our knowledge, this is the first study of cheilitis patients that has simultaneously analysed aetiological factors, characteristics of the disease and diagnostic parameters.

Cheilitis Glandularis: A clinicopathologic study with emphasis on etiopathogenesis.

OBJECTIVES: Cheilitis Glandularis (CG) is an uncommon entity of obscure etiology. A cases series is presented with emphasis on etiopathogenesis. MATERIALS AND METHODS: Fourteen CG cases were analyzed according to their demographic and clinicopathologic characteristics. RESULTS: The mean age of the patients with CG was 68.1 years, while a male-to-female ratio of 1.8:1 was observed. One or more potential causative factors were identified for each patient, including long-term smoking (9 cases), xerostomia (4 cases), cosmetic filler injections (2 cases), and actinic cheilitis (1 case). The lesions were located on the lips, buccal mucosa, or both in 7, 2, and 5 cases, respectively. Multiple submucosal nodules with dilated ductal orifices and mucous or purulent discharge were observed in all cases. Histopathologically, ductal ectasia with metaplasia, intraductal mucin, and chronic or mixed inflammation were noted, as well as pools of hyaluronic acid in 2 cases with a history of cosmetic filler injections. CONCLUSIONS: CG etiopathogenesis is probably multifactorial. Reduced salivary flow rate and increased viscosity of saliva, potentially caused by long-term smoking, diabetes mellitus, and drug-induced xerostomia, may participate in the initial pathogenesis, while local irritants, for example, poor oral hygiene and local trauma, may further contribute to the development and aggravation of the condition.

ASSOCIATION BETWEEN ALLERGIC REACTIONS AND LIP INFLAMMATORY LESIONS (CHEILITIS).

The purpose of this study was to examine the possible association between cheilitis and allergic reactions, and to use allergy skin tests to identify the allergens that induce allergic reactions in cheilitis patients (type I and type IV). We included 50 patients with recurrent cheilitis (reversible cheilitis) who were dermatologically examined and agreed to undergo allergy skin tests, i.e., patch test and prick test. Additionally, clinical pictures and patient mental stress levels were examined using the Perceived Stress Scale (PSS). Positive prick tests (atopy) were recorded in 84% of patients with cheilitis. The most frequently found allergens were contact allergens (54%) (cobalt chloride, nickel sulfate and thimerosal) and inhalant allergens (46%). The patch test positive subjects who used cosmetic, hygiene, and decorative products were significantly more likely to have swollen and red lips than the patch test negative subjects. Also, low stress levels were recorded less frequently in patients with confirmed allergies than in non-allergic patients. The results indicated a higher incidence of cheilitis in the people prone to allergies (atopics) and confirmed an association between cheilitis and allergies. To our knowledge, this is the first study in patients with cheilitis, which simultaneously analyzed allergies, their clinical features and PSS in the same patients.

Actinic cheilitis: Proposal of a clinical index.

BACKGROUND: Actinic cheilitis is a potentially malignant lesion most commonly found in the lower lip of individuals with chronic exposure to ultraviolet radiation. The aim of this study was to develop and to test a clinical index that can be used to assess the severity of actinic cheilitis. MATERIAL AND METHODS: The clinical index of actinic cheilitis was applied to 36 patients. An incisional biopsy was obtained to grade oral epithelial dysplasias following the World Health Organization (WHO) and binary systems, and to evaluate their association with clinical characteristics by Fisher's exact test (P<0.05). The accuracy of the index was evaluated based on sensitivity, specificity, positive and negative predictive values, and receiver operating curve. RESULTS: The blurring between the border of the lip and the skin was significantly associated with cases without dysplasia/mild epithelial dysplasia (P=0.041) and with low risk of malignancy (P=0.005). Ulcers and crusts were significantly associated with moderate/severe epithelial dysplasia (P=0.002 and P=0.012, respectively) and high risk of malignancy (P=0.005 and P=0.045, respectively). Erosion showed a significant association only with high-risk cases of malignancy (P=0.024). The cut-off values of the diagnostic test showing the best performance were 10 for the WHO grading system and 11 for the binary system. CONCLUSIONS: The index cut-offs with the highest accuracy were considered indicators for a biopsy. Erosion, ulceration and crusts were associated with more severe oral epithelial dysplasias.

Exfoliative cheilitis related to psychologic factors uncovered during primary immunodeficiency evaluation.

A 40-year-old previously healthy, non-atopic woman was referred for evaluation of a possible immunodeficiency disorder in the setting of an unusual erosive cheilitis and history of recurrent methicillin-resistant Staphylococcus aureus (MRSA) infection. Extensive work-up was non-diagnostic, including screening for immunologic disorders. She had failed multiple therapeutic modalities, including corticosteroid and immunosuppressive therapy. Tissue biopsy from the lip proved pivotal in demonstrating changes suggestive of factitial disease. This led to further detailed history-taking, yielding evidence of considerable psychologic distress. The patient was diagnosed with exfoliative cheilitis related to factitial disease in association with underlying untreated anxiety and psychologic trauma.

Can artificial intelligence replace manual search for systematic literature? Review on cutaneous manifestations in primary Sjögren's syndrome.

OBJECTIVES: Manual systematic literature reviews are becoming increasingly challenging due to the sharp rise in publications. The primary objective of this literature review was to compare manual and computer software using artificial intelligence retrieval of publications on the cutaneous manifestations of primary SS, but we also evaluated the prevalence of cutaneous manifestations in primary SS. METHODS: We compared manual searching and searching with the in-house computer software BIbliography BOT (BIBOT) designed for article retrieval and analysis. Both methods were used for a systematic literature review on a complex topic, i.e. the cutaneous manifestations of primary SS. Reproducibility was estimated by computing Cohen's κ coefficients and was interpreted as follows: slight, 0-0.20; fair, 0.21-0.40; moderate, 0.41-0.60; substantial, 0.61-0.80; and almost perfect, 0.81-1. RESULTS: The manual search retrieved 855 articles and BIBOT 1042 articles. In all, 202 articles were then selected by applying exclusion criteria. Among them, 155 were retrieved by both methods, 33 by manual search only, and 14 by BIBOT only. Reliability (κ = 0.84) was almost perfect. Further selection was performed by reading the 202 articles. Cohort sizes and the nature and prevalence of cutaneous manifestations varied across publications. In all, we found 52 cutaneous manifestations reported in primary SS patients. The most described ones were cutaneous vasculitis (561 patients), xerosis (651 patients) and annular erythema (215 patients). CONCLUSION: Among the final selection of 202 articles, 155/202 (77%) were found by the two methods but BIBOT was faster and automatically classified the articles in a chart. Combining the two methods retrieved the largest number of publications.

Oral and Otorhinolaryngological Findings in Adults Who Were Diagnosed With Pediatric Onset Crohn's Disease: A Controlled Study.

BACKGROUND: Up to 50% of pediatric patients with Crohn's disease (CD) report oral manifestations, but less is known about their oral health when they become adults. GOALS: Our aim was to provide detailed descriptions of the presence of oral and otorhinolaryngological manifestations in patients with pediatric onset CD once they reached adulthood, to look for predisposing factors and to compare the findings to matched controls. STUDY: Adult patients diagnosed with CD in childhood at the Children's Hospital, University of Helsinki, Finland, after 2000 were invited for a follow-up appointment in 2016 and 24 were examined by a dentist and otorhinolaryngologist. They were compared with 22 matched controls from the Population Register Centre. The participants completed questionnaires about their general health, any special diets, and their health-related quality of life. Their nutrition was evaluated from food records. RESULTS: Patients with CD had minor oral manifestations at a median of 9 years after their childhood diagnosis and the most common was angular cheilitis, which affected 6 patients and 1 control, but was not statistically significant (P=0.0984). CD with perianal abscessing disease correlated to orofacial findings (P=0.0312). Most of the patients had normal otorhinolaryngological findings. Subjects with oral lesions had lower mean health-related quality of life scores than subjects without oral findings and the differences were clinically but not statistically significant. Oral manifestations were not associated with differences in energy intake. CONCLUSIONS: Oral manifestations in adult patients with pediatric onset CD were mild and were not associated with otorhinolaryngological pathology.

Kawasaki Disease in a 3-Month-Old Infant: How to Remain Vigilant?

BACKGROUND: Kawasaki disease is an acute vasculitis occurring between 6 months and 5 years old. Patients younger than 6 months have mostly incomplete form. This clinical symptoms lead to confusion and delayed diagnosis. CASE REPORT: We developed the diagnostic difficulties with a 3-month-old infant. At the beginning, his incomplete presentation misled pediatricians. CONCLUSIONS: We highlight the possibilities of Kawasaki disease in infants younger than 6 months. Indeed, every diagnostic delay increases cardiovascular risk. Nonetheless, in our case, treatment was prescribed in the first 5 days, and the patient developed aneurysms.

Immunoexpression of glucocorticoid receptor alpha (GRα) isoform and apoptotic proteins (Bcl-2 and Bax) in actinic cheilitis and lower lip squamous cell carcinoma.

BACKGROUND: Actinic cheilitis (AC) is a potentially malignant disorder that can progress to squamous cell carcinoma (SCC), but this process is not fully understood. This study evaluated the immunoexpression of glucocorticoid receptor alpha (GRα) isoform and apoptotic proteins (Bcl-2 and Bax) in AC and lower lip SCC (LLSCC). METHODS: Twenty-two AC and 44 LLSCCs (22 with regional nodal metastasis and 22 without metastasis) were selected. The percentages of nuclear (GRα) and cytoplasmic (GRα, Bcl-2, and Bax) staining in epithelial cells were assessed and correlated with clinical (tumor size/extent and clinical stage) and histopathological parameters (risk of malignant transformation for AC and histopathological grade of malignancy for LLSCCs). RESULTS: Expression of GRα was observed in all cases studied, with relatively high median percentages of positive staining. When compared to AC, LLSCCs exhibited lower nuclear expression and higher cytoplasmic expression of GRα (P < 0.05). Regarding clinicopathological parameters, significant differences were only found for cytoplasmic expression of GRα according to the histopathological grade of LLSCCs (P = 0.036). Higher expression of Bax compared to Bcl-2 was observed in AC and LLSCCs (P < 0.05). In LLSCCs, there was a positive correlation between nuclear and cytoplasmic expressions of GRα (P = 0.006). CONCLUSION: Reduced nuclear translocation and increased cytoplasmic expression of GRα may be important events in lip carcinogenesis but are not involved in the progression of LLSCC. The role of GRα in lip cancer development does not seem to be primarily related to modulations in the expression of Bcl-2 or Bax.

Reviewing the use of imiquimod for molluscum contagiosum.

We discuss imiquimod associated with non-application site mucosal reactions and two of our own clinical cases. In one of our patients, erosive cheilitis developed in a young boy after using topical imiquimod 5% cream for 5 nights weekly on bilateral cheeks, chin, and near vermillion border for molluscum contagiosum. The case is discussed with concerns for imiquimod use in molluscum contagiosum when used near mucosal surfaces.

[A new case of Rowell's syndrome]. / Un nouveau cas de syndrome de Rowell.

INTRODUCTION: This article introduces a new case of Rowell's syndrome, a controversial entity defined by the association of lupus erythematosus and erythema multiforme. OBSERVATION: A 43-year-old woman was diagnosed with lupus erythematosus induced by esomeprazole. Because her eruption did not improve after withdrawal of the drug, hydroxychloroquine was administered. Two weeks later, the patient described new annular lesions on her chest and arms, both erosive and crusted, and some had a target-like appearance. The oral mucosa was also affected. Histology revealed sub-epidermal blistering with keratinocytic necrosis, strongly suggesting erythema multiforme. Screening for other causes of erythema multiforme proved negative. A positive outcome was achieved with corticosteroids and hydroxychloroquine. One year later, the patient was in complete remission for both lupus erythematosus and erythema multiforme. DISCUSSION: The association of lupus erythematosus and erythema multiforme first described in 1963 is known as Rowell's syndrome. While diagnostic criteria have been established in the literature, the reality of this entity is still contested. The annular lesions of subacute lupus erythematosus may be confused with the lesions of erythema multiforme. As suggested in the above section, other authors consider Rowell's syndrome to be a singular entity. Indeed, our patient developed lesions distinct from those initially suggesting subacute lupus erythematosus, in particular: the target-like aspect of the elementary lesions, mucosal involvement, a distinct histological aspect, and dissociated outcomes. Ultimately, the definition of Rowell's syndrome remains highly debated.

Sore or Swollen Lips Part 2: Systemic Causes.

This series of three papers reviews the causes, diagnosis and differential diagnosis, and outlines the management of sore and/or swollen lips. Clinical relevance: Sore and/or swollen lips are not uncommon, often have a local cause, but may reflect a systemic disease. The previous article reviewed important causes, from actinic to contact cheilitis, while this paper starts with drug-induced cheilitis and completes that alphabetical list.