In the store-and-forward teledermatology modality, there is a transfer of patient medical information electronically (including history and visual data) obtained in one location to a provider who is in another location (Roman & Jacob, 2015). The construct of the teledermatology viewpoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
TELEDERMATOLOGY READER REPORT1
History
Chief complaint: dry and burning lips.
History of Present Illness
A 5-year-old African American girl presented with dry and burning lips, which began 3 months ago. Sometimes, the patient feels soreness around her lips. To sooth the dryness and burning, the child's parent reports trying an over-the-counter lip balm, which provided minimal relief. No other treatments have been tried. The condition has been progressively getting worse. The parent reports that they recently lost a family dog, and thereafter, she noticed that her daughter had been licking her lips more frequently. The patient is doing well otherwise and has met all her developmental milestones.
IMAGE QUALITY ASSESSMENT
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
There is one image provided with this consult. The image shows a sharply demarcated erythema with apparent dryness and fissuring of both upper and lower lips including the vermillion border. A subtle hyperpigmentation can also be appreciated extending around and onto the upper and lower lips.
INTERPRETATION OF IMAGES
Findings
The morphology of the lesions, distribution, and history are characteristic of lip-licking dermatitis, aka "cheilitis simplex" (Figure 1).
RECOMMENDATIONS
Counseling the family of the benign nature of the condition and the necessity to break the habitual cycle of lip licking is recommended. It is recommended that the behavior not be punitive.
Interventions include offering an alternative (distraction/diversion) behavior to the lip licking, allowing the child to be actively engaged in the application of the moisturizing balm to the lips. It is also recommended that the proper intake of water be encouraged to increase hydration and decrease the innate lip-licking response to a dry mouth (American Academy of Dermatology, 2020).
Behavioral modification varies but includes deep relaxation techniques and competing responses (Fonseca, 2020). Patients with concomitant skin-picking disorders may benefit from cognitive behavioral therapy (Fonseca, 2020).
CLINICAL PEARL
Lip-licking dermatitis is a dermatologic manifestation of habitual licking of the lips (Jones, 1997). Contents of saliva including amylase and lipase that irritate the surrounding skin, leading to an irritant contact dermatitis (ICD) of the lips (Litchman et al., 2020). Lip-licking dermatitis is commonly seen in young children and can also be seen in pediatric patients with compulsive disorders (Chiriac et al., 2015).
ICD can be divided into acute and chronic subtypes. Physical and chemical irritants can play a role in both acute and chronic ICD (Novak-Bilic et al., 2018). In acute ICD, irritants are directly cytotoxic to keratinocytes, whereas in chronic ICD, cellular toxicity is indirectly mediated by the disruption of skin barrier (Novak-Bilic et al., 2018). When the skin barrier is compromised, irritants can penetrate into the skin and cause a chronic inflammatory reaction characterized by denaturing proteins and subsequent cellular injury and death (Novak-Bilic et al., 2018). As illustrated in this report, burning and dryness are prominent findings. Itch is less likely to be reported in chronic ICD and most often described as a classic characteristic of allergic contact dermatitis (Litchman et al., 2020).
Diagnosis of lip-licking dermatitis is primarily a clinical and observational diagnosis. The lip-licking behavior itself can often be observed during an office visit. Management consists of behavioral modification to divert the licking behavior and prevent exposure to saliva, which can promote redness, irritation, and chapping (Lugovic-Mihic et al., 2018).
Supportive treatment is the mainstay of therapy and relies on generous application of emollients such as petrolatum jelly or a ceramide-based ointment, which promotes healing process (Lugovic-Mihic et al., 2018). Low-potency topical steroids and topical calcineurin inhibitors may have a temporizing role in the treatment of the acute inflammatory phase, while the etiological component is addressed.
RECOMMENDED FOLLOW-UP
Recommend reassurance and follow-up with the primary care provider to initiate management.
REFERENCES