Approach Considerations

Treatment is difficult and unsatisfactory. In severe cases of labial swelling, medication or surgical intervention may be required, but most respond to more conservative measures.^[32]Exclusion of offending substances may help facial swelling resolve. Up to 40% of orofacial granulomatosis (OFG) patients may have positive reactions to patch tests. Half of these benefit from antigen exclusion.^[38]

Granulomatous cheilitis or OFG may improve with implementation of a cinnamon- and benzoate-free diet. Benefit has been reported in 54-78% of patients.^[39]

Intralesional corticosteroids may be helpful in some patients,^[40]and their use in combination with antibacterial drugs such as metronidazole has been an effective treatment in several instances.^{[41, 42]}Success with other treatments has been reported anecdotally, including intralesional pingyangmycin plus dexamethasone.^[43]Simple compression for several hours daily may produce sustained improvement. Compression devices can be worn overnight to reduce lip edema.

Extensive labial swelling can be disfiguring and have serious social consequences for the patient; therefore, changes in personal affect should be taken into consideration when choosing treatment options for patients with cheilitis granulomatosa.^[32]Furthermore, comorbid psychiatric diseases and other affective phenomena may be linked to relapse frequency of Miescher-Melkersson-Rosenthal syndrome.^[44]In one case, targeted psychotherapeutic intervention resulted in both decreased relapse frequency of the syndrome and remission of depression.^[44]

Surgical care

Surgery and radiation have been used in treating cheilitis granulomatosa. Surgery alone is relatively unsuccessful. Reduction cheiloplasty with intralesional triamcinolone and systemic tetracycline offers the best results.^[45]Medical therapy is necessary to maintain the results of reductive cheiloplasty during the postoperative period.^[32]Give corticosteroid injections periodically after surgery to avoid an exaggerated recurrence.

Nerve decompression has been successful in the treatment of recurrent facial nerve palsy.^[46]

Consultations

Patients with lesions apparently restricted initially to the mouth may progress to exhibit frank intestinal Crohn disease.^{[47, 48, 49]}Therefore, consult a gastroenterologist, an immunologist, a dietician, and an oral medicine specialist.

Follow-up

Follow-up care is indicated particularly to exclude the development of Crohn disease and possibly ulcerative colitis.

Medication

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Media Gallery

Orofacial granulomatosis in a patient with Crohn disease showing showing lip and gingival swelling.

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Author

Alan Snyder MD Candidate, Medical University of South Carolina College of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

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: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Additional Contributors

Crispian Scully, MD, MRCS, PhD, MDS, CBE, FDSRCS(Eng), FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, FSB, DSc, DChD, DMed(HC), Dr(HC) Emeritus Professor, University College London; Visiting Professor, Universities of Athens, BPP, Edinburgh, Granada, Helsinki and Plymouth

Crispian Scully, MD, MRCS, PhD, MDS, CBE, FDSRCS(Eng), FDSRCPS, FFDRCSI, FDSRCSE, FRCPath, FMedSci, FHEA, FUCL, FSB, DSc, DChD, DMed(HC), Dr(HC) is a member of the following medical societies: Academy of Medical Sciences, British Society for Oral Medicine, European Association for Oral Medicine, International Academy of Oral Oncology, International Association for Dental Research, International Association for Oral and Maxillofacial Pathology

Disclosure: Nothing to disclose.

Acknowledgements

David P Fivenson, MD Associate Director, St Joseph Mercy Hospital Dermatology Program, Ann Arbor, Michigan

David P Fivenson, MD is a member of the following medical societies: American Academy of Dermatology, Medical Dermatology Society, Michigan Dermatological Society, Michigan State Medical Society, Photomedicine Society, Society for Investigative Dermatology, and Wound Healing Society

Disclosure: Nothing to disclose.

Warren R Heymann, MD Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey

Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.