Exfoliative cheilitis (EC) in AIDS: association with Candida infection

Cheilitis: A Diagnostic Algorithm and Review of Underlying Etiologies

Cheilitis, or inflammation of the lips, is a common reason for dermatologic consultation. The inflammation can include the vermillion lip, vermillion border, and surrounding skin, and can present with an acute or chronic course. There are many etiologies, including irritant and allergic contact dermatitis, atopic cheilitis, actinic cheilitis, infectious etiologies, nutritional deficiencies, drug-induced cheilitis, and rare etiologies, including granulomatous cheilitis, cheilitis glandularis, plasma cell cheilitis, lupus cheilitis, and exfoliative cheilitis. Distinguishing among the various etiologies of cheilitis is clinically difficult, as many causes may produce similar erythema and superficial desquamation of mucosal skin. In addition, patients report dryness, redness, irritation, burning, fissuring, and itch in many of the underlying causes. Thus, the specific etiology of cheilitis is often difficult to diagnose, requiring extensive testing and treatment trials. In this review, we summarize the various types of cheilitis, synthesizing novel cases, clinical presentations, histopathology, epidemiology, and advancements in diagnostic methods and therapeutics. We provide a diagnostic algorithm aimed to assist clinicians in the management of cheilitis.

Predisposition of hypersensitivity in patients with exfoliative cheilitis

Background/purpose

Exfoliative cheilitis (EC) is a chronic and reversible inflammatory disease of the lips without definite etiology. Clinically, different types of allergens can be found in exfoliative cheilitis patients, however, few studies have focused on the relationship between exfoliative cheilitis and hypersensitivity. This research aimed to investigate the prevalence of hypersensitivity in EC patients.

Materials and methods

A prospective study was conducted in 30 patients with exfoliative cheilitis and 30 healthy controls, matched in age and sex. Laboratory tests included serum total IgE, allergen-specific IgE, and food-specific IgG.

Results

Increased serum total IgE level, positive food-specific IgG were seen more frequently in exfoliative cheilitis patients than in healthy control (P < 0.05). Special IgE level to FX5 and the degree of food-specific IgG to wheat were seen higher in exfoliative cheilitis patients than in healthy control (P < 0.05).

Conclusion

This study suggests that patients with exfoliative cheilitis may have predisposition of hypersensitivity. The detection of allergens should be strengthened in the future clinical work.

Topical tacrolimus with different frequency for exfoliative cheilitis: a pilot study

Background: Tacrolimus is a new type immunosuppressant. The aim of this study was to evaluate the effectiveness of topical tacrolimus 0.1% ointment at 2 different frequencies in treating patients with exfoliative cheilitis.Methods: A total of 40 patients with exfoliative cheilitis were randomly divided into the QD group receiving topical tacrolimus 0.1% ointment once a day or the QOD group receiving topical tacrolimus 0.1% ointment once-two-day. Patients were also applied wet dressing of saline twice a day. The effectiveness of treatment was defined as the percentage of improvement in signs or symptoms.Results: 37 patients completed the 2-week treatment. And, a full set was analyzed. The effectiveness of topical tacrolimus 0.1% ointment for relief in objective sign and subjective symptom was 50% and 67.5%% in the QD group, respectively. For the QOD group, the effectiveness of sign and symptom relief was 50% and 73.5%. There was no significant difference of effectiveness between application topical tacrolimus once a day and once 2 days.Conclusion: Our data suggested that application of topical tacrolimus 0.1% ointment once a day and once 2 days had similar clinical effectiveness for sign and symptom relief in patients with exfoliative cheilitis.

Differential Diagnosis of Cheilitis - How to Classify Cheilitis?

SUMMARY – Although cheilitis as a term describing lip inflammation has been identified and recognized for a long time, until now there have been no clear recommendations for its work-up and classification. The disease may appear as an isolated condition or as part of certain systemic diseases/conditions (such as anemia due to vitamin B₁₂ or iron deficiency) or local infections (e.g., herpes and oral candidiasis). Cheilitis can also be a symptom of a contact reaction to an irritant or allergen, or may be provoked by sun exposure (actinic cheilitis) or drug intake, especially retinoids. Generally, the forms most commonly reported in the literature are angular, contact (allergic and irritant), actinic, glandular, granulomatous, exfoliative and plasma cell cheilitis. However, variable nomenclature is used and subtypes are grouped and named differently. According to our experience and clinical practice, we suggest classification based on primary differences in the duration and etiology of individual groups of cheilitis, as follows: 1) mainly reversible (simplex, angular/infective, contact/eczematous, exfoliative, drug-related); 2) mainly irreversible (actinic, granulomatous, glandular, plasma cell); and 3) cheilitis connected to dermatoses and systemic diseases (lupus, lichen planus, pemphigus/pemphigoid group, angioedema, xerostomia, etc.).

Excimer laser therapy and narrowband ultraviolet B therapy for exfoliative cheilitis

BACKGROUND

Exfoliative cheilitis is a condition of unknown etiology characterized by hyperkeratosis and scaling of vermilion epithelium with cyclic desquamation. It remains largely refractory to treatment, including corticosteroid therapy, antibiotics, antifungals, and immunosuppressants.

OBJECTIVE

We sought to evaluate the safety and efficacy of excimer laser therapy and narrowband ultraviolet B therapy in female patients with refractory exfoliative cheilitis.

METHODS

We reviewed the medical records of two female patients who had been treated unsuccessfully for exfoliative cheilitis. We implemented excimer laser therapy, followed by hand-held narrowband UVB treatments for maintenance therapy, and followed them for clinical improvement and adverse effects.

RESULTS

Both patients experienced significant clinical improvement with minimal adverse effects with excimer laser therapy 600-700 mJ/cm² twice weekly for several months. The most common adverse effects were bleeding and burning, which occurred at higher doses. The hand-held narrowband UVB unit was also an effective maintenance tool.

LIMITATIONS

Limitations include small sample size and lack of standardization of starting dose and dose increments.

CONCLUSION

Excimer laser therapy is a well-tolerated and effective treatment for refractory exfoliative cheilitis with twice weekly laser treatments of up to 700 mJ/cm². Transitioning to the hand-held narrowband UVB device was also an effective maintenance strategy.

Oral candidiasis and angular cheilitis

Candidiasis, an often encountered oral disease, has been increasing in frequency. Most commonly caused by the overgrowth of Candida albicans, oral candidiasis can be divided into several categories including acute and chronic forms, and angular cheilitis. Risk factors for the development of oral candidiasis include immunosuppression, wearing of dentures, pharmacotherapeutics, smoking, infancy and old age, endocrine dysfunction, and decreased salivation. Oral candidiasis may be asymptomatic. More frequently, however, it is physically uncomfortable, and the patient may complain of burning mouth, dysgeusia, dysphagia, anorexia, and weight loss, leading to nutritional deficiency and impaired quality of life. A plethora of antifungal treatments are available. The overall prognosis of oral candidiasis is good, and rarely is the condition life threatening with invasive or recalcitrant disease.

Topical Calendula officinalis L. successfully treated exfoliative cheilitis: a case report

Authors describe a case of recurrent exfoliative cheilitis that responded to treatment with a standardized topical preparation of Calendula officinalis L. An eighteen-year-old man was referred to UNESP - São Paulo State University, Department of Biosciences and Oral Diagnosis, São José dos Campos Dental School to investigate a chronic dry scaling lesion on his lips. The patient's main chief was aesthetic compromising. Corticoid therapy was suspended and Calendula officinalis ointment 10% for ad libitum use has been prescribed. The results presented allow the authors to consider Calendula officinalis L. as a potential therapy in cases of cheilitis exfoliative.

Cheilitis as a variation of Candida-associated lesions

OBJECTIVE

Occasionally, the clinical diagnosis of Candida-associated lesion is difficult because of a variety of its clinical manifestations. There have been a few reports on Candida-associated lip lesion except angular cheilitis. In this paper, we investigate the relation of Candida in persistent lesions of the lip.

SUBJECTS AND METHODS

The present study includes consecutive nine patients with persistent erosive lip lesion. For each patient the age at presentation, gender, duration of the disease, other symptoms or signs, complete medical history and prior treatment or medications for the symptom were obtained. Then, mycological examination and the direct cytologic examination were performed.

RESULTS

The reported average duration of the disease was 7 months. Six of nine patients had received prior treatments with topical steroids at the other clinic, which failed to resolve their symptoms. Six of nine patients had a predisposing factor for candidiasis. In the culture examination, Candida albicans were isolated in seven patients (77.8%). Five of nine patients received the direct cytologic examination, and four of them revealed pseudohyphae of fungi. The anti-fungal treatment was miconazol gel 25 mg four times per day, and average duration of the treatment was 2 weeks. The outcome was as follows: complete remission in five, remarkable response in two and no response in two.

CONCLUSION

Our results suggested that one form of the varieties of Candida-associated lesions might be considered in the case of lip lesion with unknown origin that was persistent and ineffective to the topical steroids treatment.

Immunopathogenesis of oropharyngeal candidiasis in human immunodeficiency virus infection

Oropharyngeal and esophageal candidiases remain significant causes of morbidity in human immunodeficiency virus (HIV)-infected patients, despite the dramatic ability of antiretroviral therapy to reconstitute immunity. Notable advances have been achieved in understanding, at the molecular level, the relationships between the progression of HIV infection, the acquisition, maintenance, and clonality of oral candidal populations, and the emergence of antifungal resistance. However, the critical immunological defects which are responsible for the onset and maintenance of mucosal candidiasis in patients with HIV infection have not been elucidated. The devastating impact of HIV infection on mucosal Langerhans' cell and CD4(+) cell populations is most probably central to the pathogenesis of mucosal candidiasis in HIV-infected patients. However, these defects may be partly compensated by preserved host defense mechanisms (calprotectin, keratinocytes, CD8(+) T cells, and phagocytes) which, individually or together, may limit Candida albicans proliferation to the superficial mucosa. The availability of CD4C/HIV transgenic mice expressing HIV-1 in immune cells has provided the opportunity to devise a novel model of mucosal candidiasis that closely mimics the clinical and pathological features of candidal infection in human HIV infection. These transgenic mice allow, for the first time, a precise cause-and-effect analysis of the immunopathogenesis of mucosal candidiasis in HIV infection under controlled conditions in a small laboratory animal.

Oral candidal infections and antimycotics

The advent of the human immunodeficiency virus infection and the increasing prevalence of compromised individuals in the community due to modern therapeutic advances have resulted in a resurgence of opportunistic infections, including oral candidoses. One form of the latter presents classically as a white lesion of "thrush" and is usually easily diagnosed and cured. Nonetheless, a minority of these lesions appears in new guises such as erythematous candidosis, thereby confounding the unwary clinician and complicating its management. Despite the availability of several effective antimycotics for the treatment of oral candidoses, failure of therapy is not uncommon due to the unique environment of the oral cavity, where the flushing effect of saliva and the cleansing action of the oral musculature tend to reduce the drug concentration to sub-therapeutic levels. This problem has been partly circumvented by the introduction of the triazole agents, which initially appeared to be highly effective. However, an alarming increase of organisms resistant to the triazoles has been reported recently. In this review, an overview of clinical manifestations of oral candidoses and recent advances in antimycotic therapy is given, together with newer concepts, such as the post-antifungal effect (PAFE) and its possible therapeutic implications.

The concept of cellular "fight-or-flight" reaction to stress

As animals respond to environmental stress with a set of default reactions described as the "fight-or-flight" response, so do epithelial and endothelial cells when they are confronting stressors in their microenvironment. This review will summarize a growing body of data suggesting the existence of a set of stereotypical cellular reactions to stress, provide some examples of diseases that are characterized by excessive flight reactions, describe the cellular mechanisms whereby the fight-or-flight reaction is accomplished, as well as cellular mechanisms triggering either fight or flight. It is proposed that cell-matrix adhesion is a sensitive indicator of the severity of stress. This indicator is interfaced with several default programs for cellular survival or death, thus dictating the fate of the cell. Some diagnostic and therapeutic applications of the concept, presently used and potentially useful, are outlined. The essential feature of this concept is its ability to categorize cellular events in terms of either type of default reaction, predict the details of each, and potentially exploit them clinically.

Chronic fissural cheilitis: a manifestation of anterior crowding

A 48-year-old man, otherwise in good health, was seen with a chronic painful fissure of the upper lip mucosa. For at least 2 years it had failed to respond to a variety of topical agents. Though not previously reported, the primary etiologic factor was thought to be irritation from contact with his misaligned anterior teeth. Eight months into orthodontic treatment, the lesion healed and did not return. Orthodontics included preadusted edgewise mechanics. However, the right maxillary lateral incisor was not bracketed but instead guided into position by direct contact with the archwire.

Oral lesions in children with perinatally acquired human immunodeficiency virus infection

Fifteen vertically HIV-infected children aged between 2 and 12 years were followed up for 1 year, weekly to monthly, to study the incidence of oral lesions. At the time of first examination, oral candidiasis (OC) was observed in nine children. Seven children presented with the erythematous type only and two with pseudomembranous oral candidiasis. Four cases of cheilitis were seen in association with the erythematous forms of oral candidiasis. One erythematous candidiasis progressed to pseudomembranous form. A second case of erythematous OC, after multiple recurrences in the form of erythematous OC, recurred as pseudomembranous OC. Another case of erythematous OC and one of pseudomembranous OC presented after multiple recurrences as a persistent, adherent pseudomembranous OC. An orofacial herpes-zoster infection, a hairy leukoplakia and a necrotic lingual ulcer were observed as second lesions and in association with oral candidiasis in three children. Erythematous oral candidiasis was the most frequent oral HIV-related lesion, was observed in different stages of HIV-infection, and in some cases progressed to pseudomembranous candidiasis. A different, selectively resistant, Candida clone was isolated in three cases of recurrent candidiasis.

In vitro activities of antimicrobial agents against Candida species

OBJECTIVE

Antimicrobial mouthrinses may represent a valid alternative to topical antifungal agents. However, the action of antimicrobials could be affected by the different ingredients incorporated into mouthrinse products. The purpose of the present study was to investigate the in vitro antifungal and fungicidal activities of antimicrobials alone.

STUDY DESIGN

A broth macrodilution method was used to determine the minimum inhibitory concentration of 4 antimicrobial agents against Candida species. Minimum fungicidal concentration was also determined.

RESULTS

All antimicrobials showed antifungal activity against all tested organisms, but cetylpyridinium chloride received significantly lower minimum inhibitory concentrations (P < .005). Cetylpyridinium chloride also showed a greater fungicidal activity than chlorhexidine digluconate and hexetidine (P< .005), whereas sanguinarine chloride appeared to be less fungicidal against most of the isolates tested.

CONCLUSIONS

These findings suggest that cetylpyridinium chloride may be used as a topical antifungal agent. Clinical trials are now required to assess its value in the management of oral candidosis.