Winter is well underway in the Northern Hemisphere, bringing with it an increased risk of atopic dermatitis flares. Those who are well acquainted with eczema are likely being more vigilant about protecting their skin from the cold, dry air. Facial skin is particularly vulnerable during this time, simply because the face is the one part of the body that is not consistently covered when we’re out in the elements.
If you have atopic dermatitis, though, you might be overlooking an especially delicate part of your face–your lips.
Can You Get Eczema on Your Lips?
The short answer is a definite yes. There is even a name for eczema when it affects the lips: eczematous cheilitis (cheilitis from the Geek cheilo, meaning “lips,” and –itis, indicating inflammation or disease).
The skin of the lips differs visibly from other facial skin. Its distinctive properties make eczema especially uncomfortable and can complicate preventative care and treatment during flares.
Lip Eczema: A Line of Division
Perhaps you have fond memories of a parent kissing your forehead as you fell asleep as a child–or you might savor the memories of kissing your own infant’s cheek as you rocked them. Perhaps you have had an uncomfortable encounter with unexpectedly hot coffee or a slice of cheese pizza. These experiences are memorable because of the particular softness and sensitivity of the skin on your lips. Have you ever wondered why your lips are so distinct from the skin that surrounds them?
The difference begins with the thin, red perimeter of the lips, the vermilion margin. The vermilion margin marks a border between the thicker skin of the face and the thinner, more sensitive tissue of your lips. Your lips themselves are a border between the mucus membrane of your mouth and the forward-facing skin on the rest of your body.
The vermilion line also marks a border between humans and all other mammals; not even our closest cousin, the chimpanzee, has everted lips like ours. We humans rely upon our lips to communicate both verbally (several of our consonants are bilabial or labiodental–their pronunciations require the shaping of the lips) and nonverbally (smiling, sneering, and kissing).
At three to five cellular layers of thickness, the skin of your lips is much thinner than your facial skin with its 16 cellular layers. Unlike facial skin, the skin of the lips does not have a keratinized layer of skin cells to make it less permeable (remember that; this is an important key to understanding eczematous cheilitis). It is rich in superficial blood vessels and lacks hair follicles, salivary glands, sebaceous glands, and sweat glands.
The skin of the lips is also dense in nerve endings; combined with the thinner, non-keratinized epidermis we mentioned earlier, this makes them highly sensitive to touch, heat, and cold. This is probably a distinct advantage; as much as a surprisingly hot cup of coffee or molten pizza topping might hurt, the response to those stimuli usually prevents us from scalding the delicate mucosa of our mouths and throats–quite useful for the only species that cooks its food.
Lips and Eczema
The same characteristics that make a kiss enjoyable make eczematous cheilitis unbearable. Without a keratinized layer of epidermis, our lips are prone to barrier dysfunction and transepidermal water loss. This can cause problems even where eczema is not a concern; almost all of us have experienced cracked, scaling lips after a blustery or unusually dry day.
Those with a history of atopic dermatitis are more vulnerable still. About 50 percent of eczema patients have genetic mutations that contribute to weakened skin barrier function; these mutations affect the FLG gene that regulates the body’s production of filaggrin, a protein that is key in protecting the skin from water loss and external irritants. Their lips crack, scale, and bleed when triggers (such as winter weather) are encountered, and unlike a case of simple chapped lips, these flares can become chronic.
The higher sensitivity of the lips makes this cracking and scaling much more uncomfortable–and because we rely upon our lips for speech and eating, they are irritated further by constant movement and moisture.
How It Presents
A person who has never experienced eczematous cheilitis might at first believe that their lips are simply chapped. The lips become red and dry, particularly at the vermilion margin and in the skin around it. The lips then begin to scale. Eventually, fissures (cracks) form in the insulted skin, which often leads to bleeding. Patients might then notice that the corners of their mouth become involved.
The patient will experience irritation, dryness, and itching; tingling is occasionally experienced. The usual treatments for chapped lips fail to address the symptoms. A tertiary symptom is that of stress which is born form the eczema presenting itself.
What Causes Eczematous Chelitis?
Dermatologists take a thorough history when patients present with the fissuring, dryness, and redness associated with eczema of the lips. They will try to rule out other causes for the symptoms, such as psoriatic cheilitis (inflammation of the lips caused by psoriasis) or simple irritation caused by licking. If they diagnose eczema, they will then seek to narrow down the cause.
The causes of eczema on the lips can be divided into endogenous (factors present in the patient’s body, such as a pre-existing diagnosis of eczema) and exogenous (external sources of irritation and inflammation).
Atopic dermatitis is the most common endogenous cause of eczema on the lips. Many dermatologists report that 100 percent of their eczematous cheilitis patients already have a diagnosis of eczema. .
The most common exogenous causes of eczematous cheilitis are personal hygiene products (like toothpaste), and cosmetics (like lipstick). Other causes can be related to allergens or irritants in foods.
Eczema on the lips is worsened by licking the lips. In much the same way that scratching can feed an itch/scratch cycle with other kinds of eczema, licking the lips feeds a self-reinforcing loop; licking brings momentary relief, but greater transepidermal water loss occurs as the saliva evaporates. As a result, the patient’s lips are even more irritated, leading the patient to lick them again.
How Is It Treated?
The elements of treatment for eczematous cheilitis are similar to any other eczema treatment. Triggers are identified and avoided where possible. The lips are moisturized with emollients; CeraVe and Aquaphor both offer lip balms containing ceramides, which eczematous lips tend to lack. After that, a topical steroid treatment is applied. It is important to note that dermatologists recommend a preparation with a small amount of corticosteroid (such as SmartLotionⓇ).
Covering the lips with a thin layer of a heavy occlusive such as petrolatum (petroleum jelly, VaselineⓇ) can protect them from further irritation in excessively hot, cold, or windy climates. Products containing menthol, phenol, camphor, or alcohols should be avoided as they can worsen irritation. Some doctors recommend applying the occlusive multiple times every hour to prevent irritation and loss of moisture.
Irritation in the perioral region (the area immediately next to the vermilion margin) can be treated with SmartLotionⓇ according to Dr. Harlan’s protocols.
If these treatments are not effective, oral steroids might be prescribed. In some cases, topical treatment with a drug called tacrolimus is prescribed. Tacrolimus is a kind of drug known as calcineurin inhibitors. It acts to interrupt the actions of a protein called calcineurin that signals an immune response. People with atopic disorders such as eczema tend to have overactive immune systems that respond to minor irritations with a cascade of inflammation; interrupting this response can bring relief to patients whose eczema fails to respond to corticosteroids alone.
Any treatment should proceed under a doctor’s care. Eczematous cheilitis is not the only disorder that can cause the symptoms we’ve outlined. Nutritional deficiency, allergy, fungal infection and psoriasis can all cause redness and flaking of the lips. It’s important to rule these possibilities out; if the symptoms are caused by allergy, patch tests can help pinpoint the allergens at play. If there is a nutritional deficiency, it should be addressed quickly, as should a fungal infection.
Like any other experience with eczema, there are preventative measures you can take against eczematous cheilitis. Avoid known triggers and use a moisturizing lip balm daily (read the ingredients carefully for possible irritants). A heavier lip balm with dimethicone or petrolatum should be used if you anticipate spending time in windy weather or in extreme climates, and it should be reapplied frequently. Remember that your lips are subject to sun damage, also, and look for products with SPF.
If you lick your lips frequently, you might consider finding a substitute behavior to help wean you away from the habit. Some people find it helpful to apply lip balm or ointment when the urge to lick arises. Others move another part of their body, making a fist or flexing the hand when they’re tempted to lick their lips. Some recent studies suggest that journaling or doing cognitive behavior therapy exercises can be beneficial for eczema patients who are frustrated with their disorder or struggling to maintain their treatment plans.
Human lips are outliers in the animal kingdom; bizarrely everted, they are fragile, sensitive, and prone to dryness. However, they are one of our species’ evolutionary miracles. Their seemingly outlandish design allows us to speak and express our emotions without speech. And, while some of our close primate relatives do kiss, that expression of affection is uniquely important to homo sapiens. For all their fragility, our lips are a remarkable morphological feature and deserve some extra TLC–most especially if they are prone to eczema.
Interesting Facts About Lips!
- Some evolutionary biologists posit that our lips’ strange design allowed our early ancestors to thrive in the riparian environments they flocked to for water and attempts at agriculture; our soft, everted lips, they postulate, gave us an advantage when eating slippery foods such as shellfish. This is called “the aquatic ape hypothesis.”
- The vermilion of our lips is the last layer of tissue in the lips where filaggrin is found.
- The grooves in the lips are called “labial sulci,” and each person has a pattern of sulci unique to them that does not change over time. A “lip print” is so distinctive that lip prints are used for forensic identification.
If you've enjoyed our article on lip eczema, check out our other eczema and dermatology-related articles on our blog. If lip eczema is something you're struggling with, give SmartLotionⓇ, the best eczema cream, a try here.
- Zula Elwood