etiology
• chronic, excessive exposure to solar radiation; ultraviolet spectrum (ranging from 290 to 320 nm) most damaging
• fair-complexioned people more severely affected than others
• may progress to cutaneous actinic keratosis and/or squamous cell carcinoma

clinical presentation
• vermilion portion of lower lip
• pale irregularly opaque (keratotic) surface with intervening red (atrophic) zones
• obfuscated to effaced cutaneous-vermilion border
• more advanced lesions are scaly, crusted and/or indurated.
• progression to carcinoma often heralded by persistent ulceration or erosion

microscopic findings
• hyperkeratosis
• epithelial atrophy
• variable degrees of epithelial dysplasia
• amphophilic to basophilic change in submucosa (elastosis)
• telangiectasia

diagnosis
• thermal/chemical burn ruled out by history
• chronic ultraviolet light exposure
• biopsy findings

differential diagnosis
• exfoliative cheilitis
• squamous cell carcinoma
treatment
• prevention of further damage with sunscreens blocking longwave ultraviolet a (uva) and short-wave ultraviolet b (uvb) light
• biopsy of clinically suspicious areas
• co2 laser vermilionectomy
• topical 5-fluorouracil or vermilionectomy for severe disease
• excision or resection-reconstruction if malignant transformation has occurred

prognosis
• lifelong follow-up
• up to 10% develop into squamous cell carcinoma.
• when carcinoma develops, growth tends to be slow and metastasis occurs late; 85 to 90% long-term survival

etiology
• infection with a fungal organism of the candida species, usually
candida albicans
• associated with predisposing factors: Most commonly, immunosuppression, diabetes mellitus, antibiotic use, or xerostomia
(due to lack of protective effects of saliva)

clinical presentation
• acute (thrush)
• pseudomembranous
• painful white plaques representing fungal colonies on inflamed mucosa
• erythematous (acute atrophic): Painful red patches caused by acute candida overgrowth and subsequent stripping of those colonies from mucosa
• chronic
• atrophic (erythematous): Painful red patches; organism difficult to identify by culture, smear, and biopsy
• “denture-sore mouth”: A form of atrophic candidiasis associated with poorly fitting dentures; mucosa is red and painful on denture-bearing surface
• median rhomboid glossitis: A form of hyperplastic candidiasis seen on midline dorsum of tongue anterior to circumvallate papillae
• perlèche: Chronic candida infection of labial commissures; often co-infected with staphylococcus aureus
• hyperplastic/chronic hyperplastic: A form of hyperkeratosis in which candida has been identified; usually buccal mucosa near commissures; cause and effect not yet proven
• syndrome associated: Chronic candidiasis may be seen in association with endocrinopathies

diagnosis
• microscopic evaluation of lesion smears
• potassium hydroxide preparation to demonstrate hyphae
• periodic acid–schiff (pas) stain
• culture on proper medium (sabouraud’s, corn meal, or potato agar)
• biopsy with pas, gomori’s methenamine silver (gms), or other fungal stain of microscopic sections

differential diagnosis
• allergic or irritant contact stomatitis
• atrophic lichen planus

treatment
• topical or systemic antifungal agents
• for immunocompromised patients: Routine topical agents
after control of infection is achieved, usually with systemic
azole agents
• see “therapeutics” section
• correction of predisposing factor, if possible
• some cases of chronic candidiasis may require prolonged
therapy (weeks to months).

Prognosis
• excellent in the immunocompetent host

etiology
• causes may be atopic, contact, factitious, infectious, systemic,
or medication induced.

Clinical presentation
• usually involves lower lip (in both genders); can involve both
lips
• tender or asymptomatic crusts and impacted scale of vermilion
• minimal inflammation

diagnosis
• clinical appearance
• nonspecific microscopy results

differential diagnosis
• atopic cheilitis
• actinic cheilitis
• contact cheilitis

treatment
• determination of cause
• supportive care
• topical or intralesional corticosteroids, including lip ointments/
pomade (hypoallergenic)
• topical tacrolimus ointment

prognosis
• chronic
• psychologic support for factitial cheilitis

etiology
• ectopic sebaceous glands within the oral mucosa and vermilion
portion of the lips

clinical presentation
• multiple, scattered, yellowish pink, maculopapular granules
• buccal mucosa and vermilion of lips predominantly affected
• asymptomatic
• increasingly prominent after puberty

diagnosis
• bilateral distribution and appearance
• lack of symptoms
• if biopsy performed, normal sebaceous glands in the absence of
hair follicles noted

differential diagnosis
• candidiasis

treatment
• none
• reassurance

prognosis
• excellent

etiology
• unknown; may be familial
• may be related to atopy
• small percentage associated with cutaneous psoriasis
clinical presentation

• may be symptomatic in association with spicy or acidic foods
• focal red depapillated areas bordered by slightly elevated,
yellowish margin
• dynamic behavior: Changes in shape, size, intensity day to day
• dorsal and lateral tongue surfaces affected predominantly
• ventral tongue and other areas less often involved
• often associated with fissured tongue

diagnosis
• location and appearance
• biopsy confirmation usually unnecessary

differential diagnosis
• reiter’s syndrome
• lichen planus
• lupus erythematosus
• candidiasis
• psoriasis

treatment
• none, if asymptomatic
• topical corticosteroids, if symptomatic

prognosis
• excellent
• no malignant potential
• may last months to years with periods of remission

etiology
• probably due to opportunistic epstein-barr virus (ebv) infection
of epithelial cells
• usually in an immunocompromised or immunosuppressed host

clinical presentation
• usually arises on lateral tongue border
• early lesions are fine, white, vertical streaks with an overall
corrugated surface
• later lesions may be thickened to be plaque-like
• extensive lesions can involve dorsum of tongue and buccal
mucosa
• may serve as a pre-aids (acquired immunodeficiency syndrome)
sign

diagnosis
• incisional biopsy findings show characteristic ebv nuclear
inclusions in upper-level keratinocytes

differential diagnosis
• frictional hyperkeratosis
• lichen planus
• hyperplastic candidiasis

treatment
• none necessary; predisposing condition to be investigated
• can be suppressed with acyclovir for esthetics
• antiviral acyclovir
• podophyllin resin topically

prognosis
• may herald human immunodeficiency virus (hiv) disease in
vast majority of cases
• also may be present after aids is established