Description

Granulomatous cheilitis is characterised by a chronic inflammatory swelling of the lips. Yellow-orange areas are typical dermoscopic features in granulomatous disorders, and their disappearance indicates a good treatment response. Here, we describe the usefulness of dermoscopy in assessment of the treatment response and determining the treatment end point at a stage earlier than that by clinical assessment alone in a case of granulomatous cheilitis.

A woman in her 30s presented with swollen upper lip for the past few months with mild discomfort (figure 1A). Polarised dermoscopy using handyscope (FotoFinder systems GmbH, Bavaria, Germany) revealed a diffuse yellow-orange structureless background, white reticular lines and dotted vessels (figure 1B). Based on the clinical and dermoscopic features, granulomatous cheilitis was diagnosed and confirmed by histopathology. The patient was advised oral clofazimine (100 mg/day) and intralesional triamcinolone injection (10 mg/mL once every 3 weeks). Serial clinical and dermoscopic follow-up (every 3 weeks) showed a progressive reduction in swelling, and change in background colour from the pretreatment yellow-orange to yellow-white at week 3 and to pink-white at week 6 (figure 1C–F). The latter was considered a treatment endpoint and her therapy was discontinued. Review of the patient at week 9 showed further reduction in swelling (figure 1G) and dermoscopy showed complete disappearance of yellow-orange and white areas (figure 1H). A biopsy for confirmation of diagnosis revealed non-caseating dermal granulomas comprises epitheloid cells, lymphocytes and giant cells (figure 2).

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Figure 1

Pretreatment (A,B) and serial post-treatment (C–H) clinical and dermoscopic features of granulomatous cheilitis. Note the diffuse yellow-orange background on dermoscopy before treatment (B) and its progressive resolution (D,F,H) corresponding to the progressive reduction in the swelling (C,E,G). (Dermoscopy: polarised, ×20).

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Figure 2

Photomicrograph showing multiple non-caseating granulomas in the dermis. High-power view (in-set) showing epitheloid cells, lymphocytes and occasional giant cells. (H&E ×10, in-set ×40).

Granulomatous cheilitis is a component of orofacial granulomatosis—a chronic inflammatory disorder of imprecise aetiology characterised by non-caseating granulomatous inflammation of oral and maxillofacial soft tissues. It includes two conditions—Merkelsson-Rosenthal syndrome (chronic lip or facial swelling, facial palsy and fissured tongue) and granulomatous cheilitis of Miescher (swelling confined to the lips). The latter affects young adults involving one or both the lips. Various treatment modalities include systemic or intralesional steroids, clofazimine, minocycline, metronidazole, dapsone, thalidomide and surgery in recalcitrant cases or cases with severe deformation.1

Dermoscopy of various granulomatous diseases is characterised by a common feature of diffuse or localised yellow-orange areas (corresponding to the diffuse or focal granulomatous infiltration, respectively), commonly with telangiectatic vessels.2 Similar features were observed in our case, which, in conjunction with the clinical features, prompted a diagnosis of granulomatous cheilitis that was confirmed histologically. Disappearance of the yellow-orange areas is a dermoscopic indicator of disease resolution and/or a good treatment response, which was observed on serial dermoscopic follow-up in our case.3 At week 6, although swelling was still evident clinically, dermoscopy showed complete disappearance of the yellow-orange background which prompted the treatment end point. Follow-up at week 9 showed further reduction in swelling and normal lip architecture on dermoscopy despite treatment cessation at the previous visit (week 6).

This report illustrates that dermoscopy not only assists in the diagnosis of granulomatous cheilitis and assessing treatment response, it also appears to indicate the treatment end point earlier than that by clinical assessment alone.