Sore or dry lips

Introduction

The lips form a crucial anatomical and functional component of the oral cavity. They are composed of skin, vermilion border, and mucosal tissue, with abundant vascularization but limited sebaceous and sweat glands. This lack of sebaceous secretions makes the lips highly vulnerable to dryness, cracking, soreness, and inflammation.

Sore or dry lips—clinically referred to as cheilitis—may present as dryness, fissuring, redness, scaling, swelling, or ulceration. Although often benign and linked to environmental factors such as cold weather or dehydration, persistent sore or dry lips may indicate systemic diseases, nutritional deficiencies, dermatological conditions, infections, or drug-induced effects.

Management requires both symptomatic relief and addressing underlying causes.

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Anatomy and Physiology of the Lips

• Structure: The lips consist of keratinized squamous epithelium at the vermilion border and non-keratinized mucosa internally.

• Blood supply: Facial artery and superior/inferior labial arteries.

• Innervation: Trigeminal nerve (sensation) and facial nerve (motor for surrounding muscles).

• Unique features: Lack of sebaceous glands in vermilion leads to reduced natural moisture retention, predisposing to dryness and cracking.

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Etiology of Sore or Dry Lips

1. Environmental and Lifestyle Factors

• Cold, dry weather (winter-induced cheilitis).

• Excessive sun exposure (actinic cheilitis).

• Dehydration and low water intake.

• Lip licking, biting, or sucking.

• Smoking and alcohol use.

2. Infections

• Fungal infections: Candida albicans causes angular cheilitis, presenting as painful cracks at the corners of the mouth.

• Bacterial infections: Staphylococcus aureus may complicate fissured lips.

• Viral infections: Herpes simplex virus (cold sores) leads to vesicular painful eruptions.

3. Nutritional Deficiencies

• Iron deficiency anemia – causes pallor, soreness, and angular fissures.

• Vitamin B2 (riboflavin) deficiency – classic cause of angular cheilitis.

• Vitamin B12 and folate deficiency – lead to mucosal atrophy and painful lips.

• Zinc deficiency – impairs healing and causes dryness.

4. Allergic and Irritant Causes

• Allergic contact cheilitis from lipsticks, toothpaste, mouthwash, or dental materials.

• Irritant contact dermatitis from spicy foods or chemicals.

5. Dermatological Disorders

• Eczema (atopic cheilitis).

• Psoriasis affecting lips.

• Lichen planus presenting with whitish streaks or soreness.

6. Autoimmune and Systemic Conditions

• Sjögren’s syndrome (dry lips with xerostomia).

• Lupus erythematosus (discoid lupus lesions on lips).

• Crohn’s disease (swelling and fissures).

7. Medication-Induced Causes

• Retinoids (isotretinoin, acitretin).

• Chemotherapy-induced mucositis.

• Diuretics leading to dehydration.

• Anticholinergics reducing salivary flow.

8. Neoplastic Conditions

• Actinic cheilitis (premalignant lesion due to chronic sun damage).

• Squamous cell carcinoma of the lips, often presenting as a persistent sore.

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Clinical Presentation

• Dryness, scaling, and peeling.

• Cracks and fissures, especially at corners (angular cheilitis).

• Redness, swelling, and soreness.

• Burning or stinging sensations.

• Ulceration or blistering (herpetic lesions).

• Associated systemic symptoms: fatigue (anemia), xerostomia (autoimmune disease), or fever (infection).

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Diagnostic Evaluation

1. History

• Onset and duration.

• Environmental exposures.

• Nutritional intake.

• Drug history.

• Associated systemic illnesses.

2. Examination

• Distribution: corners (angular cheilitis) vs diffuse involvement.

• Type of lesions: fissures, scales, blisters, ulcers.

• Oral cavity and dentition inspection.

3. Investigations

• CBC, iron studies, vitamin B12, folate, and zinc levels.

• Swabs for fungal/bacterial culture.

• Viral swab for HSV if suspected.

• Biopsy of persistent or suspicious lesions (rule out malignancy).

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Treatment of Sore or Dry Lips

1. General Measures

• Adequate hydration (2–3 L water daily).

• Use of protective lip balms with petroleum jelly, beeswax, or lanolin.

• Sunscreen lip balms (SPF 15–30) for actinic cheilitis.

• Avoidance of lip licking, biting, and irritants.

• Humidifiers in dry environments.

2. Pharmacological Management

A. For Fungal Infections (Angular Cheilitis due to Candida)

• Topical antifungals:

  • Clotrimazole 1% cream applied to corners twice daily for 1–2 weeks.

  • Miconazole 2% cream applied twice daily for 1–2 weeks.

• Systemic antifungals (refractory cases):

  • Fluconazole 150 mg orally as a single dose, repeat weekly if required.

B. For Bacterial Infections

• Topical antibiotics:

  • Mupirocin 2% ointment applied three times daily for 7–10 days.

  • Fusidic acid 2% cream applied twice daily for 7 days.

• Systemic antibiotics (severe cases):

  • Amoxicillin 500 mg orally every 8 hours for 7 days.

  • In penicillin allergy: Clarithromycin 250 mg orally twice daily for 7 days.

C. For Viral Infections (Herpes Simplex)

• Topical antivirals:

  • Acyclovir 5% cream applied 5 times daily for 4–5 days at first sign of outbreak.

• Systemic antivirals:

  • Acyclovir 400 mg orally three times daily for 7 days.

  • Valacyclovir 1 g orally twice daily for 7 days.

D. For Nutritional Deficiencies

• Iron deficiency:

  • Ferrous sulfate 325 mg orally three times daily.

• Vitamin B2 (riboflavin) deficiency:

  • Riboflavin 10–30 mg orally daily.

• Vitamin B12 deficiency:

  • Cyanocobalamin 1000 mcg intramuscular weekly for 6 weeks, then monthly.

• Folate deficiency:

  • Folic acid 1 mg orally daily.

• Zinc deficiency:

  • Zinc sulfate 220 mg orally once daily.

E. For Inflammatory/Autoimmune Cheilitis

• Topical corticosteroids:

  • Hydrocortisone 1% cream applied thinly 2–3 times daily.

  • Clobetasol propionate 0.05% ointment for severe cases, short-term.

• Systemic therapy (severe autoimmune cases):

  • Prednisone 30–40 mg daily tapered over 7–10 days.

  • Immunomodulators (azathioprine, methotrexate) under specialist care.

F. For Actinic Cheilitis (Premalignant Lesion)

• Topical therapies:

  • 5-Fluorouracil 5% cream applied once daily for 2–4 weeks.

  • Imiquimod 5% cream applied 3 times weekly for 4–6 weeks.

• Procedures: Cryotherapy, laser ablation, or surgical excision if dysplasia suspected.

G. Pain and Symptom Control

• Topical anesthetics:

  • Lidocaine viscous 2% solution applied to affected area every 3–4 hours as needed.

• Systemic analgesics:

  • Paracetamol 500–1000 mg every 6–8 hours (maximum 4 g/day).

  • Ibuprofen 400 mg every 8 hours if not contraindicated.

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Precautions and Lifestyle Advice

• Use lip balms regularly, particularly in cold or dry weather.

• Avoid smoking and alcohol, which worsen dryness and delay healing.

• Avoid cosmetic products with allergens (fragrances, preservatives).

• Wash hands before applying topical medications to lips.

• Patients with recurrent herpes should start antiviral therapy at the first sign of tingling.

• Immunocompromised patients must seek medical advice early for persistent lesions.

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Drug Interactions

• Fluconazole – increases plasma levels of warfarin, statins, and certain antidiabetics.

• Acyclovir/Valacyclovir – may interact with nephrotoxic drugs (cyclosporine, aminoglycosides).

• Iron supplements – interfere with absorption of tetracyclines and quinolones; should be taken 2 hours apart.

• Corticosteroids – long-term use may increase risk of oral candidiasis and systemic side effects.

• 5-Fluorouracil cream – contraindicated in pregnancy; avoid combination with systemic fluoropyrimidines.

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Prognosis

• Simple environmental cheilitis usually resolves with hydration and emollients.

• Infectious cheilitis responds well to topical or systemic antimicrobials.

• Nutritional deficiency–related cheilitis improves once supplementation is initiated.

• Autoimmune and premalignant conditions may require long-term monitoring and specialist management.

• Actinic cheilitis carries a risk of malignant transformation and must be treated aggressively.