The lips are a unique type of tissue that acts as a barrier for the mouth and is exposed to various substances that can impact the skin. Additionally, being a highly visible part of the body, even mild rashes can cause significant psychological distress.
Eczema of the lips & mouth
July 5, 2023
Rashes on the lips and mouth, is it eczema or could it be something else?
Introduction:
Facial rashes involving the lips and areas around the mouth are common. The lips are a unique type of tissue that acts as a barrier for the mouth and are subsequently exposed to many potentially rash-triggering substances which can cause skin irritation. Due to the location of the lips and area around the mouth being in the centre of our face rashes involving this area can cause significant psychological impact even when only mildly affected.
Diagnosing these rashes can be difficult as different conditions can present with similar appearances and symptoms. Identifying the underlying cause is key as treatments for some rashes can exacerbate others. Treatments also need to be used cautiously as facial skin is delicate and more susceptible to adverse side effects.
Article Outline:
- Understanding the different lip and peri-oral rashes
- Managing lip and peri-oral rashes
- Frequently Asked Questions (FAQ)
1. Understanding the different lip and peri-oral rashes
Dermatitis and eczema are descriptive terms which refer to inflammation within the skin but aren't specific to a specific underlying cause. Cheilitis is the name given to lip inflammation, this term similarly covers several different conditions with separate underlying causes.
Atopic Dermatitis
Atopic Dermatitis (AD, Atopic Eczema), often synonymous with eczema, is a chronic skin condition caused by genetic factors which lead to a compromised skin barrier function and an overactive immune system. It typically emerges in early childhood and follows a cycle of recurring flare-ups and periods of remission. Common symptoms of eczema include itchiness and dry skin which can be accompanied by soreness, weeping, and alterations in skin colour. Typically the condition becomes less severe in adulthood. In young children, it is common for eczema to affect the cheeks while in adults it more commonly affects the eyelids and areas around the mouth. The word atopic refers to allergies where the reaction occurs away from the site of contact with the allergen. For example, in young children, food allergies can drive flares of eczema (this is very uncommon in adults). Triggers of eczema flare-ups include environmental factors such as dry air (cold weather, air conditioning), harsh soaps and rough fabrics (wool).
Contact Dermatitis (Allergic & Irritant)
Contact dermatitis is a type of eczema where skin inflammation is caused by direct contact with a substance.
Irritant Contact Dermatitis (ICD) - ICD occurs upon direct exposure of the skin to irritant substances, usually manifesting within a few hours of contact. It commonly affects individuals with previously damaged, dry, or thin skin, where the skin's protective barrier is compromised.
Allergic Contact Dermatitis (ACD) - ACD arises from substances triggering an allergic response in the skin, typically developing 1-2 days after exposure. The delayed reaction time often complicates the identification of the trigger substance.
Specific conditions of the lips and skin around the mouth
Inflammation of the lips (lip dermatitis) can be caused by multiple different factors from skin irritation, allergic reaction, fungal infection, bacterial infection and repetitive behaviours. Establishing an accurate diagnosis is key to determining the correct treatment plan and achieving control of symptoms.
Atopic cheilitis
Atopic cheilitis is the specific name given to lip eczema. The condition usually presents with swollen, flaky lips which may be red in individuals with lighter skin tones. The condition often involved the vermillion border (border between the lips and facial) and the perioral skin vs the lips themselves. Symptoms of lip eczema include soreness and itchiness and can be resistant to typical steroid treatments. The key diagnostic feature of atopic cheilitis is the individual's history of atopic dermatitis affecting other areas of the body.
Lip-lickers dermatitis
Lip-lickers dermatitis / chelitis simplex - is a specific type of irritant dermatitis involving the lips and areas around the mouth. It is caused by excessive saliva contact with the skin leading to skin dryness and inflammation. It is often seen in extreme weather conditions and can present as dry, cracked lips, and can spread further to the area around the mouth. Recurrent licking of the lips removes the oily surface that protects the lips, while the enzymes in saliva can directly irritate lips leading to inflammation.
Angular cheilitis
Angular cheilitis typically involves the corners of the mouth. It is often associated with vitamin and mineral deficiencies. It is more common in winter and can be exacerbated by lip licking and saliva. It is more common in the winter when additional lip licking worsens the condition. It is more commonly seen in individuals with atopic dermatitis and is often associated with bacterial or candidal infection is common.
Contact/eczematous cheilitis
Contact/eczematous cheilitis is a type of lip eczema caused by direct contact with an irritant (irritant contact cheilitis) or allergy (allergic contact cheilitis) triggering substance - typical causative substances include toothpaste, food and objects put into the mouth. It typically presents as dryness, scaling, redness and fissuring of the skin around the mouth vs on the lips themselves. This condition is more common in an individual with a history of atopic dermatitis.
Exfoliative chelitis
Exfoliative chelitis presents with peeling of the outer border of the lips followed by large flaking of the skin on the lips. It often only involves one lip (lower) and can be seen in individuals who frequently moisturise their lips, open-mouth breathing, lip licking, sucking and picking the lips.
Peri-orofacial dermatitis
Peri-orofacial dermatitis (perioral dermatitis) - Is a condition which causes redness, spots and occasionally blisters around the mouth and the grooves on the side of the nose. There is often a distinct border of unaffected skin between the lips and affected skin. It mainly affects women (90%) and is strongly associated with the use of topical steroids on the face. Candida (thrush) and bacterial growth are associated with the condition but are not thought to be infective.
2. Managing lip and peri-oral rashes
Atopic Dermatitis (AD):
Management strategies for atopic dermatitis involve repairing the compromised skin barrier, suppressing inflammation and identifying and avoiding triggers. Effective treatment for eczema includes:
Moisturisers: Crucial for restoring the skin's natural barrier function by hydrating the skin and preventing moisture loss. Managing dry skin helps prevent the penetration of possible triggers through the skin. They are important as a preventive measure / general skin maintenance as well as for tackling acute flares and itchy skin.
Steroids and Topical Calcineurin Inhibitors (TCIs): Both steroids and TCIs are applied as topical creams, and are used as flare control creams. Due to the more delicate nature of the skin on the face, weaker potency steroids should be used and long-term use avoided to reduce the risks of adverse side effects.
Trigger Avoidance: Vital in managing AD. Avoiding or minimising exposure to possible triggers including soaps, cleansing products, hot water, dry air and rough fabrics is essential for symptom control. As this is a chronic condition complete control may be challenging due to numerous triggering factors, awareness and avoidance, along with consistent moisturiser use and early flare-control treatment, help minimise symptoms.
Eczema symptoms and itchiness can be managed through cooling the skin see our dedicated page here on managing eczema symptoms - LINK.
Contact Dermatitis (ICD & ACD)
Management involves:
Trigger Identification and Avoidance: Paramount in both irritant and allergic contact dermatitis. Once the causative agent is identified, preventing further exposure is crucial.
Similar Treatment Approaches: Moisturisers, Topical Corticosteroids (TCS), and Topical Calcineurin Inhibitors (TCIs) are used similarly to manage symptoms. Complete control is achievable if the trigger can be identified and avoided.
Cheilitis
Atopic cheilitis
Given this is a form of atopic dermatitis it is managed similarly to how the condition is managed on other areas of skin through the use of moisturisers, topical steroids and TCI’s. Strong topical steroid preparations should be avoided on the face due to the increased risk of adverse side effects. TCI’s are useful for reducing steroid use and for steroid-resistant flares. Prevention is achieved through managing triggers, regular application of moisturisers and prompt flare management.
Lip-lickers dermatitis/cheilitis simplex
Given the core feature of this is skin dryness, the focus of management is the application of moisturisers and barrier products to protect the skin including lip balms and vaseline. If specific triggering behaviours are identified ie lip-licking then this needs to be stopped. Occasionally low-potency topical steroids are required.
Angular cheilitis
Treatment involves the management of predisposing factors, where vitamin deficiencies are suspected taking supplements or altering the individual's diet is important. In certain individuals, topical antifungals, antibiotics and low-potency steroids can be used.
Contact/eczematous cheilitis
For individuals with contact cheilitis, the focus of management is the identification of triggers and subsequent avoidance. There is a broad spectrum of irritants and allergens associated with this subtype from cosmetics, to toothpaste, foods and objects put in the mouth (pens). Where allergic contact cheilitis is suspected patch testing is used to identify causative substances. Moisturisers and low-moderate potency steroids are used to manage flares.
Exfoliative cheilitis
Management includes avoidance of triggering behaviour alongside the use of topical steroids, TCI’s and Topical Calendula officinalis L (Marigold extract).
Periorofacial dermatitis
Given the known association of the condition with topical steroid use, it is important to avoid further steroid contact with the face - this is particularly important for individuals who might be using steroids to manage skin conditions on other parts of the body. Therefore washing the hands thoroughly to avoid transfer to the face is crucial. For some individuals avoiding the application of all products to the face alone will lead to the resolution of symptoms, often with a brief worsening of symptoms over 2-3 days before steady improvement. For those which don’t resolve spontaneously topical antibiotics can be used and in the most severe instances, oral antibiotics are required.
3. FAQ’s
If I use topical steroids on my face will I develop peri-orofacial dermatitis?
Peri-orofacial dermatitis is associated with topical steroid use but the relationship is complicated. Ultimately it is rare - one large study only reported 10 cases in a group of 85,280 who were actively using steroids LINK. Despite this for individuals that do develop the condition steroids are often involved to some extent. What complicates this further is steroids are often prescribed inappropriately early in the condition's presentation, leading to transient improvement in symptoms followed by flares on withdrawal of the product. It is thought that the use of steroids may allow increased colonisation of yeasts and bacteria which may contribute to the condition developing. So the short answer is no - but if you do develop the condition then steroids are likely to be a contributing factor.
Are steroids safe to use on my face?
Topical steroids are important medications for the treatment of many skin conditions and when used appropriately are safe and useful tools to manage facial skin conditions. However, it is crucial to know what condition you are treating as some conditions can make things worse (ie peri-orofacial dermatitis). It is also important to use the right potency steroid, mild and moderate potency topical steroids can be safe if used in a controlled and limited fashion.
What natural products can be used on the face?
This depends on your personal history, if you have a history of eczema/atopic dermatitis it is important to be cautious when applying any product to the skin as the chemicals in the product may cause irritation and inflammation, triggering flares. If using a new product it's best to trial the substance on a patch of healthy skin for a few weeks before applying it on any broken skin.
Calendula officinalis ointment (made from Marigold extract) has been proven to help treat exfoliative cheilitis and has both antiseptic and antifungal properties.
