Medical Care
The approach to treatment for cheilitis glandularis is based on diagnostic information obtained from histopathologic analysis, the identification of likely etiologic factors responsible for the cheilitis glandularis, 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 cheilitis glandularis. Therefore, treatment for cheilitis glandularis 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.
In cheilitis glandularis cases in which lip biopsy demonstrates chronic inflammation without evidence of epithelial atypia or dysplasia and no suggestion of deep infection, Bovenschen reported successful treatment using combined oral minocycline (100 mg once per day) plus tacrolimus ointment 0.1% twice daily for 6 weeks. [21] Another case report describes successful palliative treatment with topical tacrolimus and pimecrolimus in cheilitis glandularis superimposed on oral lichen planus. [22]
Surgical Care
In cheilitis glandularis 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, [15, 16, 23] 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.
In cases in which dryness is attributable to documented Sjögren syndrome, referral to a rheumatologist and a dentist are recommended for further systemic workup, ongoing follow up, and preventive care.
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. [24] 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. [25]
Prevention
Where relevant, patients who habitually lick their lips should be advised to avoid this behavior.
Sun-protective measures (eg, wearing a hat with a visor, lip balm with sun-blocking agents, avoidance of direct and protracted sun exposure) must also be instituted.
Long-Term Monitoring
Monitor patients with documented actinic cheilitis with clinical observation once or twice a year for an indefinite period. This is because, in some cases, cheilitis glandularis has the potential for the development of lip carcinoma. Also, some patients with cheilitis glandularis may be at risk for the development of suppurative episodes if trauma to the lip surface is continuous. This can result in chronic ulceration or erosion, leading to portals of entry for bacterial invasion and inflammatory sequelae.
Clinical evidence of disease progression mandates biopsy and an appropriate treatment plan (topical chemotherapy with 5-fluorouracil or vermilionectomy, or in cases of squamous cell carcinoma, lip wedge resection).
Decisions concerning the advisability and timing of surgical cheiloplasty or vermilionectomy can be challenging in patients who exhibit clinical evidence of persistent habitual or deliberate factitial injury. Undertaking surgery is ill advised if the source of irritation or trauma is perpetuated. Patients who are highly symptomatic and/or functionally compromised by lip enlargement and its complications should be offered the option of surgical debulking, regardless of the cause. Whether or not the surgical approach is ultimately successful depends on factors unique to the patient.
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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.
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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).
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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).
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Note the fullness of the lower portion of the lip and the indistinct junction between the vermilion border and the skin.
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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).
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High-power photomicrograph of the minor salivary glands. Note ductal ectasia, acinar atrophy, interstitial fibrosis, and inflammation (hematoxylin and eosin, original magnification X100).
