Exfoliative Cheilitis- From Challenges to Cure: A Case Report

INTRODUCTION

Exfoliative cheilitis (EC) is a rare, chronic inflammatory disorder of the lips characterized by continuous desquamation of the superficial keratin layer, resulting in thick adherent scales, fissuring, and variable discomfort. Despite being benign, its recurrent nature and visible presentation significantly affect facial aesthetics, often leading to functional limitations and psychological distress.^[1]

The etiology of EC remains uncertain, with proposed contributing factors including habitual lip trauma such as lip licking or biting, infections, nutritional deficiencies, and underlying psychiatric conditions like anxiety or depression.^[2] Differentiating EC from clinically similar conditions, such as actinic cheilitis, granulomatous cheilitis, and infectious cheilitis, is essential due to differences in prognosis and treatment.^[3]

Management of EC poses a significant challenge, as conventional therapies, including corticosteroids, emollients, antifungals, keratolytics, and psychotherapy, often provide only temporary relief.^[4] Interest in phytotherapeutic agents has grown due to their anti-inflammatory and wound-healing properties. Calendula officinalis, rich in flavonoids, saponins, and carotenoids, has demonstrated antimicrobial, anti-inflammatory, and tissue-regenerative benefits, making it a promising alternative therapy.

This report describes a recurrent case of EC successfully managed with topical Calendula officinalis ointment, emphasizing its potential as a natural, cost-effective, and well-tolerated treatment option for persistent EC.

CASE REPORT

A 21-year-old female presented to the Department of Oral Medicine and Radiology. She complained of persistent dryness, cracking, excessive scaling, and intermittent itching and burning of both lips for 7–8 years. Symptoms worsened in dry weather and caused significant cosmetic distress, leading to reduced social interaction. The patient had no significant medical or family history. She denied systemic symptoms such as fever, weight loss, or allergies. Psychosocial assessment revealed habitual lip-licking behavior triggered during stress, particularly examination periods. Her diet was irregular and nutritionally inadequate due to erratic meal patterns. Prior dermatologic management included topical emollients and antifungal ointments, but no clinical improvement was observed.

Extraoral examination revealed thick, yellowish-white keratinized scales over the vermilion border of the upper and lower lip [Figure 1]. Gentle removal of the scales exposed normal-appearing underlying mucosa with mild erythema and superficial fissures. No ulceration, crusted bleeding, vesicles, nodularity, or purulence was noted. Regional lymph nodes were non-tender and not enlarged. Intraoral examination revealed no additional mucosal lesions.

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Figure 1:

Extraoral profile of patient on OPD visit

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Based on the clinical presentation of persistent lip desquamation, fissuring, and keratinized scaling, a provisional diagnosis of Eczematous cheilitis was made.

To confirm the diagnosis, an incisional biopsy from the lower lip was performed under local anesthesia.

The main diagnostic challenge lay in distinguishing this condition from other lip disorders with overlapping clinical features. Differential diagnoses considered and subsequently ruled out included EC, plasma cell cheilitis, cheilitis glandularis, actinic cheilitis, and allergic cheilitis. The patient’s prior lack of response to antifungal therapy further complicated the diagnostic process by initially suggesting an infectious component that was ultimately unsupported. Additionally, psychosocial stress and habitual lip-manipulating behaviors contributed to the persistence of symptoms.

Histopathological evaluation revealed marked hyperkeratosis, acanthosis, mild chronic inflammatory infiltrate in the underlying connective tissue, lymphocytic infiltration, and no dysplasia [Figure 2].

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Figure 2:

Hyperkeratosis and thickness of spinous cell layer with marked inflammatory infiltrate (Hematoxylin and Eosin stain X20)

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To rule out nutritional deficiencies, other laboratory investigations were done, which included: Complete Blood Count: Hemoglobin 8.4 g/dL; RBC count 3.78 million/cu mm; WBC count 3200/cu mm (low), vitamin D levels: 11.2 ng/mL (low), and vitamin B12 levels: 160 pg/mL (low).

Additionally, psychological evaluation using the Hospital Anxiety and Depression Scale (HADS) revealed elevated scores, reflecting psychosocial distress associated with the condition.

Definitive diagnosis of EC was established based on correlating with clinical findings, histopathological features, and exclusion of alternative diagnoses. The condition was classified as benign but chronic with potential for recurrence. With correction of nutritional deficiencies, psychological counselling, and targeted pharmacologic therapy, the patient’s prognosis was considered favorable, with low recurrence risk under sustained behavioral modification. In Figure 3 Administering intralesional corticosteroid and Figure 4 shows the first visit for intralesional corticosteroid injection, and Figure 5 shows significant resolution of the lesion on the third visit for intralesional corticosteroid injection.

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Figure 3:

Administering intralesional corticosteroid

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Figure 4:

First visit for intralesional corticosteroid injection

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Figure 5:

Third visit for intralesional corticosteroid injection

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A combined pharmacologic, psychological, and supportive management plan was adopted. Administration of interventions included intralesional corticosteroids, which were administered as: triamcinolone acetonide 40 mg/mL every 10 days for one month (total 3 sessions).

Topical therapy included tacrolimus 0.1% ointment applied twice daily and Calendula officinalis

ointment applied three times daily. Systemic oral supplements were prescribed as blood investigations revealed nutritional deficiencies. These included elemental iron 60 mg once daily for 60 days and a daily multivitamin tablet. Psychological counselling was done for stress management training, behavioral modification, and engagement in recreational activities. Supportive care included hydrating lip balm, maintaining good oral hygiene, diet enriched with vitamin A, vitamin B12, iron, zinc, and avoidance of allergenic cosmetics or lip products.

The HADS score demonstrated a steady reduction:

• Initial visit: HADS score 18, indicating significant anxiety related to impaired quality of life.

• Second visit: HADS score 12, showing improvement in confidence and symptom relief.

• After 21 days of follow-up: HADS score was 5, reflecting marked psychological and clinical improvement.

• At 3-month and 6-month follow-up: HADS score 0, indicating a complete absence of anxiety or depression symptoms.

Repeat hematological values showed improvement in hemoglobin and normalization of Vitamin levels. No further pathological signs were observed on clinical examination.

The patient demonstrated excellent adherence to topical applications, supplements, and counselling sessions. Tolerability was assessed during scheduled follow-up visits and through patient self-reporting. No discomfort or irritation from topical agents was noted.

No adverse reactions, allergic responses, or procedural complications were encountered. The patient remained stable throughout treatment. No recurrence was reported during the 3-month follow-up evaluation [Figure 6].

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Figure 6:

Completely healed, resolved lesion on lips post-treatment upon 3-month follow-up

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DISCUSSION

EC is a benign yet chronic inflammatory disorder of the lips that affects facial aesthetics, communication, and quality of life.^[1] This case reflects established clinical patterns in the literature and highlights the multifactorial etiology, chronicity, and management challenges of EC. Strengths include comprehensive evaluation, exclusion of differential diagnoses, and successful multimodal therapy, while limitations involve the inability to determine a definitive cause and the difficulty of assessing behavioral habits that rely on patient self-reporting.^[2]

Current literature describes EC as multifactorial, commonly linked to parafunctional lip habits, psychological stress, nutritional deficiencies, and occasional opportunistic infections.^[3] Lip licking, biting, and peeling are consistently reported triggers that perpetuate excessive keratinization, while stress reinforces these behaviors.^[4] Deficiencies in iron and vitamin B12 impair epithelial turnover, supporting findings in our patient. Though largely idiopathic, cases associated with immunosuppression and chronic infections have been reported.^[5]

Clinically, EC presents with thick keratinized scales, crusting, fissuring, erythema, and discomfort.^[6] Removal of scales typically exposes normal or mildly inflamed mucosa. The vermilion’s thin stratum corneum, lack of adnexal structures, and high transepidermal water loss predispose it to irritation and delayed healing.^[7] Diagnosis is primarily exclusion-based, supported by history, physical examination, and histopathology, which commonly shows hyperkeratosis and acanthosis.^[8]

Treatment remains challenging due to the absence of a single effective modality. Literature supports individualized, multimodal therapy incorporating habit cessation and psychological counselling, supported by topical agents such as emollients, keratolytics, tacrolimus, and herbal formulations like Calendula officinalis.^[8] Intralesional corticosteroids help reduce inflammation, while nutritional supplementation is essential when deficiencies exist. Emerging therapies, including photodynamic therapy and fractional CO₂ lasers, have shown encouraging results in improving epithelial regeneration.^[9]

The favorable outcome in this patient can be attributed to correction of deficiencies, behavioral modification through counselling, and targeted pharmacologic therapy. This supports the scientific rationale for multimodal management of EC as recommended in current literature.

CONCLUSION

This case report is that EC, though benign, is a chronic and distressing condition requiring careful clinical assessment and exclusion of other pathologies. Its prognosis depends significantly on recognizing behavioral and psychological contributors alongside physical manifestations. A multimodal treatment plan, comprising behavioral modification, psychological support, nutritional correction, and targeted pharmacologic therapy, proved effective in this case. The primary takeaway message is that long-term improvement in EC is most successfully achieved when management addresses both the emotional and habitual factors underlying the condition, ensuring sustained healing and reducing recurrence risk.