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Cheilitis Glandularis Workup

  • Author: Ellen Eisenberg, DMD; Chief Editor: William D James, MD  more...
 
Updated: Feb 22, 2016
 

Laboratory Studies

To rule out systemic granulomatous diseases (eg, sarcoidosis, Crohn disease), perform ACE levels, erythrocyte sedimentation rate, and CBC count and differential.

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Imaging Studies

Reflectance confocal microscopy (RCM) was recently described by Laurenco et al. This is a noninvasive imaging technique that allows for in vivo en face visualization of tissues with resolution that approaches that of conventional microscopy. With RCM, the entire lip can be examined nonsurgically, from surface to deeper stromal structures. According to the investigators who applied RCM to patients with clinical features consistent with cheilitis glandularis, correlating the clinical, digital RCM images, and histopathology improved diagnostic skills in the evaluation of clinical findings suggestive of cheilitis glandularis.[17]

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Other Tests

Microbial culture and sensitivity testing may be warranted. In cases with acute or chronic suppuration, bacterial culture and sensitivity testing is indicated for selection of appropriate antibiotic therapy.

Fungal culture or smear may be warranted. Chronic angular cheilitis or erosive surface changes may be indicative of chronic candidal infection. Confirmation is an indication for appropriate antifungal therapy.

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Procedures

Lip biopsy is indicated to rule out specific granulomatous diseases that predispose to lip enlargement and to aid in establishing a definitive diagnosis. A representative incisional biopsy specimen should consist of a wedge (or punch) of lip tissue that includes surface epithelium and is of adequate depth to ensure inclusion of several submucosal salivary glands.

Labial minor salivary gland biopsy (ie, sampling 8-10 labial minor salivary glands obtained through an incision into the mucosa of the lower lip) should be performed if Sjögren syndrome is suspected.

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Histologic Findings

The term cheilitis glandularis is a provisional clinically descriptive designation rather than a definitive diagnosis. It refers to a constellation of clinical findings that can reflect a broad scope of possible histologic changes; therefore, no consistent or pathognomonic features of this disorder are seen at the microscopic level. Instead, a diverse array of possible alterations can be seen in both the surface epithelium and the submucosal tissues. These findings best enable the clinician to presumptively determine the etiology and the nature of an individual case.

The maturational profile of the epithelium can be essentially normal or show evidence of disturbance that ranges from varying degrees of atypia or dysplasia to frank carcinoma. Epithelial alterations attended by basophilic collagen degeneration (solar elastosis) constitute a diagnosis of actinic cheilitis. The presence of epithelial maturational disturbance indicates risk for progression to carcinoma.

The minor salivary glands may appear normal under the microscope, or they may exhibit various changes indicative of nonspecific sialadenitis. These changes can include atrophy or distention of acini, ductal ectasia with or without squamous metaplasia, chronic inflammatory infiltration and replacement of glandular parenchyma, and interstitial fibrosis. Suppuration and sinus tracts may be present in cases that involve bacterial infection.

Other possible histologic findings include stromal edema, hyperemia, surface hyperkeratosis, erosion, or ulceration.

Note the images below.

Medium-power photomicrograph. Note mildly atypical Medium-power photomicrograph. Note mildly atypical epithelial maturation, modest lymphocytic infiltrate within the lamina propria region, and the striking basophilic collagen degeneration within the superficial stroma plus telangiectasias. The composite features are consistent with a diagnosis of actinic cheilitis (hematoxylin and eosin, original magnification, X100).
Low-power photomicrograph. Deep submucosa of the l Low-power photomicrograph. Deep submucosa of the lip. Several minor salivary glands demonstrate ductal ectasia, interstitial inflammation, atrophy, and fibrosis. No evidence of salivary gland hypertrophy is seen (hematoxylin and eosin, original magnification X40).
Lip biopsy specimen. Low-power photomicrograph rev Lip biopsy specimen. Low-power photomicrograph reveals focal surface hyperkeratosis accompanied by vascular congestion and fibrosis of the underlying stroma (hematoxylin and eosin, original magnification X40).
High-power photomicrograph of the minor salivary g High-power photomicrograph of the minor salivary glands. Note ductal ectasia, acinar atrophy, interstitial fibrosis, and inflammation (hematoxylin and eosin, original magnification X100).
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Contributor Information and Disclosures
Author

Ellen Eisenberg, DMD Professor and Section Chair, Section of Oral and Maxillofacial Pathology, Division of Oral and Maxillofacial Diagnostic Sciences, Department of Oral Health and Diagnostic Sciences, University of Connecticut School of Dental Medicine; Associate Professor, Division of Anatomic Pathology, Department of Pathology and Laboratory Medicine, University of Connecticut School of Medicine, University of Connecticut Health Center

Ellen Eisenberg, DMD is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, American Association of University Professors, American Dental Education Association, Connecticut Society of Oral and Maxillofacial Surgeons, Connecticut Society of Pathologists, Eastern Society of Teachers of Oral Pathology, International Academy of Oral and Maxillofacial Pathology

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Mark W Cobb, MD Consulting Staff, WNC Dermatological Associates

Mark W Cobb, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society of Dermatopathology

Disclosure: Nothing to disclose.

References
  1. Neville BW, Damm DD, Allen CA, Bouquot JE. Salivary Gland Pathology. Neville BW, Damm DD, Allen CA, Bouquot JE, eds. Oral and Maxillofacial Pathology. 3rd ed. St Louis, Mo: Saunders Elsevier; 2009. 462-3.

  2. von Volkman R. Einege Falle von Cheilitis Glandularis Apostematosa (Myxadenitis Labialis). Virchows Arch Pathol Anat [A]. 1870. 50:142-4.

  3. Sutton RL. Cheilitis glandularis apostematosa (with case report). J Cutan Dis. 1909. 27:151-4.

  4. Sutton RL. The symptomatology and treatment of three common diseases of the vermilion border of the lip. Int Clin (series 24). 1914. 3:123-8.

  5. Swerlick RA, Cooper PH. Cheilitis glandularis: a re-evaluation. J Am Acad Dermatol. 1984 Mar. 10(3):466-72. [Medline].

  6. Stoopler ET, Carrasco L, Stanton DC, Pringle G, Sollecito TP. Cheilitis glandularis: an unusual histopathologic presentation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Mar. 95(3):312-7. [Medline].

  7. Musa NJ, Suresh L, Hatton M, Tapia JL, Aguirre A, Radfar L. Multiple suppurative cystic lesions of the lips and buccal mucosa: a case of suppurative stomatitis glandularis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Feb. 99(2):175-9. [Medline].

  8. Reichart PA, Scheifele Ch, Philipsen HP. [Glandular cheilitis. 2 case reports]. Mund Kiefer Gesichtschir. 2002 Jul. 6(4):266-70. [Medline].

  9. Leao JC, Ferreira AM, Martins S, et al. Cheilitis glandularis: An unusual presentation in a patient with HIV infection. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Feb. 95(2):142-4. [Medline].

  10. Butt FM, Chindia ML, Rana FS, Ashani A. Cheilitis glandularis progressing to squamous cell carcinoma in an hiv-infected patient: case report. East Afr Med J. 2007 Dec. 84(12):595-8. [Medline].

  11. Carrington PR, Horn TD. Cheilitis glandularis: a clinical marker for both malignancy and/or severe inflammatory disease of the oral cavity. J Am Acad Dermatol. 2006 Feb. 54(2):336-7. [Medline].

  12. Parmar RC, Muranjan MN. A newly recognized syndrome with double upper and lower lip, hypertelorism, eyelid ptosis, blepharophimosis, and third finger clinodactyly. Am J Med Genet A. 2004 Jan 15. 124A(2):200-1. [Medline].

  13. Cohen DM, Green JG, Diekmann SL. Concurrent anomalies: cheilitis glandularis and double lip. Report of a case. Oral Surg Oral Med Oral Pathol. 1988 Sep. 66(3):397-9. [Medline].

  14. Dhanapal R, Nalin Kumar S, Saraswathi TR, et al. Maxillary double lip and cheilitis glandularis: An unusual occurence. J Oral Maxillofac Pathol. 2007. 11:35-7. [Full Text].

  15. Nico MM, Nakano de Melo J, Lourenço SV. Cheilitis glandularis: a clinicopathological study in 22 patients. J Am Acad Dermatol. 2010 Feb. 62(2):233-8. [Medline].

  16. Winchester L, Scully C, Prime SS, Eveson JW. Cheilitis glandularis: a case affecting the upper lip. Oral Surg Oral Med Oral Pathol. 1986 Dec. 62(6):654-6. [Medline].

  17. Lourenço SV, Kos E, Borguezan Nunes T, Bologna SB, Sangueza M, Nico MM. In vivo reflectance confocal microscopy evaluation of cheilitis glandularis: a report of 5 cases. Am J Dermatopathol. 2015 Mar. 37 (3):197-202. [Medline].

  18. Bovenschen HJ. Novel treatment for cheilitis glandularis. Acta Derm Venereol. 2009. 89(1):99-100. [Medline].

  19. Erkek E, Sahin S, Kilic R, Erdogan S. A case of cheilitis glandularis superimposed on oral lichen planus: successful palliative treatment with topical tacrolimus and pimecrolimus. J Eur Acad Dermatol Venereol. 2007 Aug. 21(7):999-1000. [Medline].

  20. Lourenço SV, Gori LM, Boggio P, Nico MM. Cheilitis glandularis in albinos: a report of two cases and review of histopathological findings after therapeutic vermilionectomy. J Eur Acad Dermatol Venereol. 2007 Oct. 21(9):1265-7. [Medline].

  21. Aydin E, Gokoglu O, Ozcurumez G, Aydin H. Factitious cheilitis: a case report. J Med Case Reports. 2008 Jan 29. 2:29. [Medline].

  22. Michalowski R. Munchausen's syndrome: a new variety of bleeding type-self-inflicted cheilorrhagia and cheilitis glandularis. Dermatologica. 1985. 170(2):93-7. [Medline].

  23. Bender MM, Rubenstein M, Rosen T. Cheilitis glandularis in an African-American woman: response to antibiotic therapy. Skinmed. 2005 Nov-Dec. 4(6):391-2. [Medline].

 
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A 56-year-old woman with an 18-month history of chronic swelling and a dry, burning sensation in her lower lip. She reports intermittent increases and decreases in size of the lip with painful episodes of erosion, crusting, and rare instances of drainage. History reveals medication-induced xerostomia plus a tendency to compulsively lick the lip to maintain hydration. Note eversion of the mucosal surface, which appears erythematous and dry, and narrowing of the vermilion border. The lower labial mucosa appears nodular; however, on palpation, it is diffusely soft. The composite features are consistent with a clinical impression of cheilitis glandularis. A lip biopsy sample was obtained.
Medium-power photomicrograph. Note mildly atypical epithelial maturation, modest lymphocytic infiltrate within the lamina propria region, and the striking basophilic collagen degeneration within the superficial stroma plus telangiectasias. The composite features are consistent with a diagnosis of actinic cheilitis (hematoxylin and eosin, original magnification, X100).
Low-power photomicrograph. Deep submucosa of the lip. Several minor salivary glands demonstrate ductal ectasia, interstitial inflammation, atrophy, and fibrosis. No evidence of salivary gland hypertrophy is seen (hematoxylin and eosin, original magnification X40).
Note the fullness of the lower portion of the lip and the indistinct junction between the vermilion border and the skin.
Lip biopsy specimen. Low-power photomicrograph reveals focal surface hyperkeratosis accompanied by vascular congestion and fibrosis of the underlying stroma (hematoxylin and eosin, original magnification X40).
High-power photomicrograph of the minor salivary glands. Note ductal ectasia, acinar atrophy, interstitial fibrosis, and inflammation (hematoxylin and eosin, original magnification X100).
 
 
 
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