Causes of Cheilitis
Cheilitis has multiple etiologies including infectious (fungal and bacterial), contact reactions (irritant and allergic), environmental exposures (actinic damage), nutritional deficiencies, drug-induced causes, and associations with systemic diseases and dermatologic conditions. 1, 2
Infectious Causes
Fungal Infections
- Candida species, primarily Candida albicans, are the most common fungal pathogens causing angular cheilitis, particularly in patients with macerated skin at the corners of the mouth 3, 4
- Fungal overgrowth occurs in moist, macerated skin and is associated with antimicrobial and corticosteroid use 3
- Dermatophyte infections can also affect the lips, though less commonly than Candida 3
Bacterial Infections
- Staphylococcus aureus frequently contributes to angular cheilitis, often in combination with Candida 3, 5
- Beta-hemolytic streptococci, especially Streptococcus pyogenes, can cause lip inflammation 3
- Mixed bacterial-fungal etiology is common in angular cheilitis 5
Contact-Related Causes
Irritant Contact Cheilitis
- Primary irritants causing direct damage to lip tissue include cosmetics, lip balms, toothpaste, and environmental factors like wind and cold 1, 2
- Chronic lip licking and mouth breathing create persistent moisture and irritation 6, 4
Allergic Contact Cheilitis
- Delayed hypersensitivity reactions to contactants such as fragrances, preservatives, and metals (particularly nickel) 1, 7
- Allergens in lipsticks, dental products, foods, and medications 1, 2
Environmental and Physical Causes
Actinic Cheilitis
- Chronic sun exposure causing premalignant changes, primarily affecting the lower lip 1, 2, 7
- This represents a distinct premalignant condition requiring different management than infectious cheilitis 8, 6
Mechanical Factors
- Ill-fitting dentures causing chronic irritation and moisture accumulation 6, 4
- Loss of vertical dimension leading to skin folds at mouth corners 6, 4
- Trauma from piercings, with potential for jewelry-related complications 3
Nutritional Deficiencies
- Riboflavin (vitamin B2) deficiency is classically associated with angular cheilitis 4
- Iron deficiency and anemia contribute to cheilitis development 4, 2
- Vitamin B12 deficiency can manifest as lip inflammation 2
Drug-Induced Causes
Retinoid-Related Cheilitis
- Oral isotretinoin causes cheilitis in the majority of patients, with lip dryness being the most frequent side effect 3
- Acitretin produces similar mucocutaneous effects including cheilitis, dry mouth, and thirst 3
- The combination of cheilitis and Staphylococcus aureus colonization during isotretinoin therapy can rarely cause lip or perioral abscesses 3
Severe Drug Reactions
- Stevens-Johnson syndrome and toxic epidermal necrolysis cause severe mucosal involvement including the lips 3, 9
- DRESS syndrome may present with lip inflammation 9
- Erythema multiforme can affect the lips 9
Associated Dermatologic Conditions
Atopic Dermatitis
- Upper lip cheilitis is quite specific for atopic dermatitis but uncommon, listed as a minor diagnostic criterion in the Hanifin and Rajka criteria 3
- Atopic cheilitis represents lip involvement in patients with generalized atopic disease 1, 9
Other Dermatoses
- Lichen planus can involve the lips with characteristic findings 9
- Psoriasis may present with lip involvement 9
- Autoimmune bullous diseases including pemphigus and pemphigoid can affect the lips 9
- Discoid lupus erythematosus may cause lupus cheilitis 9, 7
Systemic Disease Associations
Inflammatory Conditions
- Crohn's disease can manifest as orofacial granulomatosis with lip involvement 9, 7
- Sarcoidosis may present with granulomatous cheilitis 9, 7
- Melkersson-Rosenthal syndrome includes cheilitis granulomatosa as a component 9, 7
Immunocompromised States
- Diabetes mellitus increases susceptibility to infectious cheilitis 6, 4
- Immunosuppression from any cause predisposes to fungal and bacterial lip infections 6, 4
Sjögren's Syndrome
- Xerostomia and oral dryness contribute to cheilitis development 3
- Angular cheilitis occurs with painful sores or red patches at mouth corners 3
Rare and Specific Causes
Glandular Disorders
- Cheilitis glandularis is a chronic inflammatory disorder of labial salivary glands with premalignant potential 1, 7