Which medical conditions are associated with dry, peeling lips?

Medical Conditions Causing Dry, Peeling Lips

Dry, peeling lips can result from medication side effects (particularly anticholinergics, stimulants, and retinoids), autoimmune diseases (especially Sjögren's syndrome), nutritional deficiencies, environmental factors, and systemic inflammatory conditions, with Kawasaki disease being a critical pediatric consideration when accompanied by fever. 1, 2, 3

Medication-Induced Causes

Medications are among the most common culprits for dry, peeling lips through anticholinergic or sympathomimetic effects:

• Stimulant medications including lisdexamfetamine (Vyvanse) and phentermine cause dry mouth and lips in a significant percentage of users through sympathomimetic mechanisms 2
• Anticholinergic medications such as tricyclic antidepressants, centrally acting anticholinergics, and cyclobenzaprine reduce salivary flow 2
• SSRIs, particularly fluoxetine at higher doses, cause dry mouth with greater frequency and severity at higher doses 2
• Beta-blockers (atenolol, metoprolol, propranolol) cause dry mouth through anti-adrenergic effects 2
• Retinoids (oral and topical) are well-known for causing lip dryness, fissuring, peeling, and cracking as a common adverse effect 1, 4
• Opioids commonly cause dry mouth as an adverse effect 2
• Anti-obesity medications including phentermine/topiramate and naltrexone/bupropion list dry mouth as a common side effect 2

Autoimmune and Systemic Diseases

Several autoimmune conditions specifically target salivary glands or manifest with lip involvement:

• Sjögren's syndrome is characterized by lymphocytic infiltration of salivary glands, affecting approximately 0.4% of the population with a 20:1 female-to-male ratio, representing a primary autoimmune cause of xerostomia and dry lips 2
• Systemic lupus erythematosus and discoid lupus erythematosus can present with cheilitis and dry lips 2, 4
• Lichen planus may involve the lips with red and white changes, though intraoral involvement is usually more prominent 4, 5
• Primary biliary cholangitis commonly presents with sicca complex including dry mouth and lips 2
• Rheumatoid arthritis can cause salivary gland hypofunction 2

Nutritional Deficiencies

Specific vitamin and mineral deficiencies directly cause lip inflammation and dryness:

• Vitamin B12 deficiency causes cheilitis as part of systemic manifestations 3, 4
• Iron deficiency anemia presents with cheilitis and dry, cracked lips 3, 4
• Nutritional deficiencies in general are recognized causes of cheilitis associated with systemic disease 4

Pediatric Emergency: Kawasaki Disease

In children with fever, dry cracked lips are a diagnostic criterion for Kawasaki disease, a potentially life-threatening vasculitis:

• Kawasaki disease presents with erythema, dryness, fissuring, peeling, cracking, and bleeding of the lips as one of the principal diagnostic features 1
• Requires fever persisting at least 5 days plus at least 4 principal features including lip changes 1
• Critical pitfall: This diagnosis must not be missed in febrile children as untreated disease causes coronary artery aneurysms and long-term cardiac morbidity 1

Environmental and Contact Causes

External factors and irritants commonly cause reversible cheilitis:

• Cheilitis simplex (chapped lips) results from dry or hot environments, mouth breathing, or lip licking habits 3, 6, 5
• Contact cheilitis (allergic or irritant) occurs from exposure to cosmetics, dental products, foods, or other contactants 3, 4, 6
• Actinic cheilitis develops from chronic sun exposure, particularly affecting the lower lip in light-skinned individuals, and represents a potentially malignant disorder 3, 4, 5
• Exfoliative cheilitis presents with persistent scaling and peeling, often associated with lip licking or picking behaviors 3, 4

Infectious Causes

Infections can present with or exacerbate lip dryness and peeling:

• Angular cheilitis presents as red, sometimes infected lesions at the commissures, often with secondary fungal or bacterial infection requiring antifungal and antibiotic treatment 4, 5
• Oral candidiasis can mimic or coexist with xerostomia 2, 3
• Herpes labialis causes acute lip lesions but is typically vesicular rather than primarily dry and peeling 4, 5

Systemic Metabolic Conditions

Several metabolic and chronic diseases contribute to xerostomia and dry lips:

• Diabetes mellitus is commonly associated with dry mouth in typical patient age ranges 2
• Heart failure and renal failure are associated with dry mouth 2
• Metabolic syndrome is associated with xerostomia in elderly patients 2

Age-Related Factors

Physiologic changes with aging predispose to lip dryness:

• Salivary flow rate declines with age, making older adults more susceptible to dry mouth and lips even without other risk factors 2
• Elderly patients face substantially higher risk due to multiple medications combined with age-related decline in salivary flow 2

Other Dermatological Conditions

Primary skin diseases may manifest on the lips:

• Atopic dermatitis may present with chapped lips (cheilitis sicca) as the only manifestation or part of generalized disease 4, 6
• Psoriasis can involve the lips 2, 4
• Autoimmune bullous diseases (pemphigus/pemphigoid group) may affect the lips 3, 4

Critical Clinical Approach

When evaluating dry, peeling lips, prioritize:

1. Medication review - the most common reversible cause in adults 2
2. Fever assessment in children - to exclude Kawasaki disease 1
3. Nutritional status - particularly B12 and iron levels 3, 4
4. Autoimmune screening if sicca symptoms are present (dry eyes, dry mouth) - consider Sjögren's syndrome 2
5. Environmental factors - sun exposure, lip licking, mouth breathing 3, 6, 5

Common pitfall: Do not assume all dry lips are simply "chapped lips" from weather - systematic evaluation prevents missing serious underlying conditions like autoimmune disease, nutritional deficiencies, or in children, Kawasaki disease 1, 2, 3, 4