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    Stubborn ring of rash around a boy's mouth

     

    Differential diagnosis

    Lip-licking dermatitis may be confused with periorificial dermatitis, allergic contact dermatitis, atopic dermatitis, seborrheic dermatitis, and candidiasis (angular cheilitis or perlèche).1-3

    ·      Periorificial dermatitis may develop around the eyes, nose, and mouth in children and young adults and probably represents a variant of rosacea. It also has been associated with the use of topical and inhaled steroids. However, unlike lip-licking dermatitis, it spares a narrow zone immediately adjacent to the vermilion.

    ·      Allergic contact dermatitis can present similarly to irritant contact dermatitis, but history would reveal exposure to triggering substances such as lipsticks, dental products or devices, musical instruments, food, or medication. Atopic dermatitis would typically affect other areas of the body and favor flexural or extensor surfaces depending on the patient’s age.

    ·      Seborrheic dermatitis presents with erythema with overlying yellow greasy scale that favors the scalp, eyebrows, and nasolabial folds. Perioral distribution is not typical for seborrheic dermatitis.

    ·      Perlèche can present similarly but oral involvement typically occurs in patients with underlying illness or who are immunosuppressed. It would normally respond to topical antifungal therapy.

    Lip-licking dermatitis is a clinical diagnosis based on history and physical examination. Often parents or the physician observe repeated lip-licking behavior that can lend support to the diagnosis.

    Management

    The main goal of therapy is to break the frequent wet-dry cycle, restore water and lipid content to the skin surface, reduce inflammation, and prevent further transepidermal water loss.1 Generous and frequent application of emollients, such as petroleum jelly, provides a barrier that can help retain moisture and enhance the efficacy of topical medication.5

    Next: Acute pruritic eruption on a child's face and hands

    A short course of low- to mid-potency topical steroids or topical immunomodulators (tacrolimus ointment or pimecrolimus cream) may expedite resolution in more recalcitrant conditions.1-3 However, topical steroids must be monitored to avoid chronic use, which may result in the development of periorificial dermatitis. Patient and parents should know that complete resolution and absence of recurrence necessitate eliminating the inciting factor, which in this case is repeated licking of the lips. Behavioral therapy may be necessary, and it can be very effective in modifying the habitual practice.6,7

    Patient outcome

    The patient and his mother were educated on the etiology of this condition. The boy was counseled that minimizing or stopping his habitual lip-licking could greatly improve the dermatitis. He was also advised to start twice-daily application of topical tacrolimus 0.1% ointment in conjunction with frequent use of emollient at least 5 to 10 times a day. A follow-up visit 4 months later showed dramatic improvement, and he was advised to continue frequent emollient application.

    REFERENCES

    1.    Weston WL. Contact dermatitis in children. UpToDate. Available at: https://www.uptodate.com/contents/contact-dermatitis-in-children. Updated March 7, 2017. Accessed September 7, 2017.

    2.    Fox A, Dasher D, Bernhard JD, et al. Lip-licking dermatitis. VisualDx. Available at: https://www.visualdx.com/visualdx/diagnosis/lip-licking%20dermatitis?diagnosisId=53407&moduleId=10. Updated February 12, 2015. Accessed September 7, 2017.

    3.    Watt CJ, Hong HC. Dermacase. Lip licker's dermatitis. Can Fam Physician. 2002;48:1051, 1059.

    4.    Marks JG Jr, Miller JJ. Structure and function of the skin. In: Lookingbill and Marks’ Principles of Dermatology. 5th ed. Elsevier Saunders; 2013:2-10.

    5.    Buraczewska I, Berne B, Lindberg M, Törmä H, Lodén M. Changes in skin barrier function following long-term treatment with moisturizers, a randomized controlled trial. Br J Dermatol. 2007;156(3):492-498.

    6.    Azrin NH, Nunn RG, Frantz-Renshaw SE. Habit reversal vs negative practice treatment of self-destructive oral habits (biting, chewing, or licking of the lips, cheeks, tongue, or palate). J Behav Ther Exp Psychiatry. 1982;13(1):49-54.

    7.    van de Griendt JM, Verdellen CW, van Dijk MK, Verbraak MJ. Behavioural treatment of tics: habit reversal and exposure with response prevention. Neurosci Biobehav Rev. 2013;37(6):1172-1177.

    Erina Lie, BS, MS4
    Ms Lie is a fourth-year medical student at Johns Hopkins University School of Medicine, Baltimore, Maryland.

    1 Comment

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    • UBM User
      The most effective moisture barrier remains Chapstix - creams and ointments easily removed with single lip-licking manuever. Chronic condition is frequently a mixture of bacterial and fungal pathogens that can be KOH and/or culture-proven and will require a mixed approach. Caution with topical steroids and tinea incognito. Tongue Piercings and braces can cause nickel-allergy dermatitis with clinical appearance similar to lip licking dermatitis and difficult resolution until nickel contact is eliminated. Very nice write-up and photographs - Thank You!

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