this is the latest letter from one of the many derms i am seeing have a read might find some of it interesting.
This 23-year-old man presents with at least two-year history of intractable cheilitis.
It affects the upper and lower lips and somewhat atypically it doesn’t affect the surrounding skin principally the mucosal side of the lips.
Multiple tests have been performed. Multiple specialists have been seen. Dermatologists have been consulted both locally and in Western Australia. Even immunology was consulted in Western Australia.
Multiple diagnoses have been considered from immune blistering condition such as pemphigus to lichen planus to granulomatous cheilitis in the context of Crohn’s disease (he had a colonoscopy, which proved negative).
Previous biopsies and swabs have only ever shown Candida species and staph aureus. Histology has never shown picture specific to immunobullous disorders, lichen planus, lupus erythematosus nor granulomatous cheilitis.
He has tried with diet to avoid potential allergens, the picture is not clearly that of allergy.
There is absolutely no personal nor family history of dermatoses of relevance including no personal nor family history of eczema or psoriasis.
He is otherwise entirely healthy. The picture is not that of a vitamin or essential elements deficiency.
He denies lip licking and during the consultation today there was no lip licking.
What is interesting is that he has quite extensive nail pitting.
He has absolutely no other manifestations though of Psoriasis anywhere on the body.
Clearly very problematic for the patient.
The thought that this might represent HSV has been considered although swabs as well as serology have always been negative and I don’t think in his case therefore this is relevant.
I think we should return to a very basic regimen controlling the bacteria and fungi, which are known to be contributors in his case using Nilstat oral drops 1 mL four times a day in upcoming weeks. He should swish that around for a few minutes before spitting it out. I have asked him to use rifampicin and Bactroban concomitantly to eradicate staph species, I have encouraged the use of Bactroban to the lips and Chlorhexidine based allover facial wash.
I have also suggested UV therapy be trialled. I have had a number of people with intractable lip problems for whom UV therapy has been extraordinarily effective.
With the only other positive finding dermatologically being quite prominent nail pitting, a localized but kobnerising Psoriasis is at this point at the lot of my DDx list.
Review by me personally in four weeks has been offered. We will be in touch!