eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa
Cheilitis Glandularis: Treatment & Medication
Updated: Dec 31, 2008
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- Differential Diagnoses & Workup
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Treatment
Medical Care
The approach to treatment is based on diagnostic information obtained from histopathologic analysis, the identification of likely etiologic factors responsible for the condition, and attempts to alleviate or eradicate those causes. Given the relatively small number of reported cases of cheilitis glandularis, neither sufficient nor reliable data exist with regard to medical approaches to the condition. Therefore, treatment varies accordingly for each patient.
- For cases attributable to angioedema, administration of an antihistamine may effect temporary reduction in acute nonpurulent swelling.
- Suppurative cases of cheilitis glandularis require management with appropriate antimicrobial treatment as determined by culture and sensitivity testing. Concomitant intralesional or oral corticosteroid treatment may potentiate the effectiveness of antimicrobial therapy in cases with nodularity; however, the potential systemic adverse effects of long-term corticosteroid treatment, plus its propensity for promoting local fibrosis and scarring, limit its potential use either as an adjunct to antibiotic treatment or as a single therapeutic modality for cheilitis glandularis.
- Topical 5-fluorouracil is useful for treatment of dysplastic actinic cheilitis and to curtail its progression. In conjunction with clinical supervision, it can be prescribed as an alternative to vermilionectomy or as a prophylactic measure following vermilionectomy.
Surgical Care
In cases in which a history of chronic sun exposure exists (especially if the patient is fair skinned or the everted lip surface is chronically eroded, ulcerated, or crusted), biopsy is strongly recommended to rule out actinic cheilitis or carcinoma.
- Surgical excision is not necessary when the diagnosis is actinic cheilitis with atypia or only mild dysplasia; however, patients require ongoing clinical vigilance at regular intervals and instruction in measures to protect the lips from further sun damage.
- Treatment options for cases of actinic cheilitis with moderate-to-severe dysplasia include surgical stripping or vermilionectomy, cryosurgery or laser surgery, or topical chemotherapy with 5-fluorouracil. Given the potential for recurrence and the risk for development of carcinoma, sun protective measures and regular clinical monitoring must be instituted.
- Carcinoma of the vermilion is treated with surgical wedge resection with adequate margins or vermilionectomy. A palpatory examination of the submental lymph nodes is indicated to rule out regional metastasis.
- In cases in which eversion, extensive fibrosis, and induration have resulted in lip incompetence with functional and cosmetic compromise, chronic pain, and surface disruption, debulking with surgical cheiloplasty is indicated to restore normal lip architecture and function. Cheiloplasty is also a prophylactic measure for reducing the risk of actinic injury.
Consultations
- Consultation with the patient's other providers regarding the possibility of prescribing alternative, less desiccating medications is indicated in cases where medication-induced xerostomia is believed to be contributory to or causative of lip dryness.
- Patients with angioedema or atopic dermatitis (cheilitis) with or without a personal or family history of allergic rhinitis, asthma, or urticaria could benefit from consultation with an allergist-immunologist.
- Psychiatric consultation is recommended in cases where psychogenic factors appear to be contributory. Clinical and historical evidence or suspicion of deliberate, self-inflicted injury to the lip (Munchausen syndrome) should prompt referral for a psychiatric evaluation, particularly if a surgical treatment approach is being considered.16
Medication
For cases attributable to angioedema, administration of an antihistamine may effect temporary reduction in acute nonpurulent swelling. Suppurative cases of cheilitis glandularis require management with appropriate antimicrobial treatment as determined by culture and sensitivity testing. Concomitant intralesional or oral corticosteroid treatment may potentiate the effectiveness of antimicrobial therapy in cases with significant nodularity; however, potential systemic adverse effects of long-term corticosteroid treatment, plus propensity for promoting local fibrosis and scarring, limit its potential use either as an adjunct to antibiotic treatment or as a single therapeutic modality for cheilitis glandularis.
Topical 5-fluorouracil is useful for the treatment of dysplastic actinic cheilitis and to curtail its progression. In conjunction with clinical supervision, it can be prescribed as an alternative to vermilionectomy or as a prophylactic measure following vermilionectomy.
Antihistamines
These agents are used to treat angioedema or suspected allergic reaction.
Diphenhydramine (Benadryl)
For symptomatic relief of symptoms caused by release of histamine in allergic reactions.
Adult
25-50 mg PO q6-8h prn for 48 h; not to exceed 300 mg/d
Alternatively, 10-50 mg IM/IV q2-3h; not to exceed 400 mg/d
Pediatric
<6 years: 6.25-12.5 mg PO q4-6h
6-12 years: 12.5-25 mg PO q4-6h; not to exceed 150 mg/d
>12 years: Administer as in adults
Potentiates effect of CNS depressants; because of alcohol content, do not give syr dosage form to patient taking medications that can cause disulfiramlike reactions; concomitant alkaloids present in belladonna, antidepressants with strong anticholinergic effects (eg, amitriptyline, trimipramine, amoxapine, doxepin, imipramine, nortriptyline, maprotiline), or phenothiazines with strong anticholinergic effects (eg, chlorpromazine, triflupromazine, thioridazine) and antihistamines may increase possibility of adynamic ileus, urinary retention, or chronic glaucoma (more prominent in elderly patients)
Documented hypersensitivity; acute asthma; newborns; breastfeeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction; elderly persons more susceptible to adverse effects; caution in history of bronchial asthma, cardiovascular disease or hypertension; may cause excitation in young children
Pyrimidine antagonists
These agents are used to treat actinic cheilitis (dysplastic).
Fluorouracil (Efudex, Fluoroplex, Carac)
Interferes with DNA synthesis by blocking methylation of deoxyuridylic acid, inhibiting thymidylate synthetase and subsequently cell proliferation. Topical forms approved for actinic keratoses; only 5% (Efudex) form approved for superficial basal cell carcinoma.
Adult
Apply 0.5-5% strength thinly to affected area qd/bid for 2-4 wk
Pediatric
Not established
None reported
Documented hypersensitivity; potentially serious infections
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Inflammatory reactions may occur with use of occlusive dressings; porous gauze dressing may be applied for cosmetic reasons without increase in reaction; patients should expect inflammatory reaction with crusting; because contraindicated for use on mucous membranes, cream rather than liquid form is preferable for use on vermilion surface; duration of application to lip may be shorter than on skin because of its propensity to induce intense inflammatory responses
Corticosteroids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.
Prednisone (Deltasone, Orasone)
Immunosuppressant for treatment of autoimmune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Stabilizes lysosomal membranes and also suppresses lymphocyte and antibody production. Single morning dose is safer for long-term use, but divided doses have more anti-inflammatory effect.
Adult
0.5-2 mg/kg/d (around 1 mg/kg/d) PO; taper as condition improves
Pediatric
Administer as in adults but dose more around 1-2 mg/kg/d range
Coadministration with estrogens may decrease clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase the metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics; coadministration with ritonavir may significantly increase serum concentrations of prednisone; concomitant therapy with montelukast may result in severe peripheral edema; clarithromycin may increase risk of psychotic symptoms
Documented hypersensitivity; viral, fungal, tubercular skin, or connective tissue infections; peptic ulcer disease; hepatic dysfunction; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May unmask hypertension or diabetes or exacerbate peptic ulcer disease and tuberculosis; long-term sequelae associated with long-term steroid use include osteoporosis, cataracts, and pituitary-hypothalamic axis suppression; with high doses, patients may develop a steroid psychosis and are at increased risk of infections, particularly when oral steroids are used in conjunction with other immunosuppressants; frequently monitor patient's blood glucose level, blood pressure, and weight; monitor for Cushing syndrome
In cheilitis glandularis, persistent swelling or increasing nodularity are indications for ceasing intralesional or PO use
More on Cheilitis Glandularis |
| Overview: Cheilitis Glandularis |
| Differential Diagnoses & Workup: Cheilitis Glandularis |
 Treatment & Medication: Cheilitis Glandularis |
| Follow-up: Cheilitis Glandularis |
| Multimedia: Cheilitis Glandularis |
| References |
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References
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Further Reading
Keywords
cheilitis glandularis, CG, suppurative sialadenitis, suppurative stomatitis glandularis, actinic cheilitis, squamous cell carcinoma, myxadenitis labialis, cheilitis apostematosa, Baelz disease, Baelz's disease
