[Cutaneous leishmaniasis of the vermilion border of the upper lip extending to the oral mucosa]

BACKGROUND

Cutaneous leishmaniasis is endemic in Morocco. Mucosal involvement is rare. We report a case in Morocco of cutaneous leishmaniasis of the vermilion border of the upper lip extending to the oral mucosa due to Leishmania tropica.

PATIENTS AND METHODS

A 15-year-old girl was seen with 2 ulcerated lesions, present for 4 months, situated on the left cheek and vermilion border and extending to the oral mucosa. The diagnosis of leishmaniasis was confirmed by direct examination revealing high numbers of Leishmania amastigotes. Culture of the offending organism in NNN medium and isoenzymatic characterization resulted in identification of L. tropica. Treatment with meglumine antimoniate (Glucantime) was ineffective. The outcome was good after treatment with fluconazole.

CONCLUSION

In Morocco, cutaneous leishmaniasis with mucosal involvement is rare, and usually develops as a complication of cutaneous leishmaniasis via direct extension.

Pyogenic Granuloma of the Lip With Complete Resolution After Topical Propranolol

To the Editor: An otherwise-healthy 27-year-old male patient presented with a 3-month history of an asymptomatic, non-bleeding, rapidly growing nodule, on his left upper vermilion lip.

Eosinophilic pustular folliculitis with labial and oral involvement: report of a rare presentation

Eosinophilic pustular folliculitis (EPF) is a recurrent inflammatory dermatosis primarily involving hair follicles. Several subtypes of EPF have been described: Classic EPF, infantile EPF, and immunosuppression-associated EPF. Although classic EPF has a predilection for face, involvement of hairless areas such as palms and soles has been reported frequently. There are rare case reports of mucosal EPF. Herein, we report a woman who presented with classic EPF involving the lip and oral mucosa.

Decreased Labial Herpes Simplex Virus Outbreaks Following Botulinum Neurotoxin Type A Injection: A Case Report

Herpes Labialis results from reactivation of latent herpes simplex virus (HSV-1 or HSV-2) harbored in the trigeminal ganglion during times of psychological stress, cutaneous injury or photo exposure. Following reactivation, the virus is anterogradely transported through axonal termini to the skin where the virus is released and replicates causing a clinical outbreak. Botulinum neurotoxin A (BoNTA) is known to inhibit presynaptic neuropeptide and neurotransmitter release. Whether it has the capacity to interfere with viral shedding and delivery into the skin remains unclear. We were interested in determining whether BoNTA could serve as a potential therapeutic or prophylactic treatment approach for frequent and severe HSV recurrences. We describe a clinical case report in which a patient successfully maintained a sustained absence of HSV outbreaks in regions where BoNTA was intradermally administered. BoNTA may offer a novel therapeutic approach for preventing recurrent HSV disease. J Drugs Dermatol. 2018;17(10):1127-1129.

An extraordinary case of syphilis presenting with a labial ulcer

In the differential diagnosis of patients with ulcers on the lips characteristics like the duration of the ulcer, number, size, depth, shape, base, margins, and distribution are considered. Such ulcers arise from many diseases particularly, viral and bacterial infections, malignancies can also be responsible. Classic syphilitic chancres are painless erosions settled on hard papule; these are evident in the genital area in more than 90% of patients. This study describes a case of a 38-year-old female patient presenting with a painful ulcer covering 3 quarters of the upper lip showing settlement on erythematous, edematous, and indurated plaque covered with hemorrhagic crusts. The aim of this study was to consider differences between the classic syphilitic chancre typically found in the genital region from extragenital chancres and to raise awareness of the possibility of primary syphilis when patients present with painful ulcers on the lip.

Social exclusion and myiasis of the upper lip in a Brazilian rural resident

CONTEXT

People living in rural or remote Brazil, as in other sub-tropical or tropical nations, are vulnerable to infections that would not normally occur in urban areas or wealthier nations. Brazil is a geographically extensive nation, historically marked by vast socioeconomic inequalities. Approximately 16% of the population live in rural areas.

ISSUE

This clinical case report demonstrates the vulnerability of rural residents who are underserved by Brazil's 'universal' public healthcare system, despite social and economic challenges that increase their risk for disease. Myiasis (especially oral myiasis) is a rare health condition in humans caused by fly larvae. Oral myiasis usually appears in periodontal pockets and open wounds, such as after dental extractions. It is associated with poverty, lack of access to health care, and very poor overall health status. While myiasis has a worldwide distribution, it is particularly associated with the tropical and sub-tropical regions of North and South America.

LESSONS LEARNED

This article describes a rare case of myiasis in the upper lip of a rural male patient. The case report demonstrate that rural and remote residents can be socially excluded from the benefits of technology and biomedicine, making them vulnerable to rare infections.

Exclusive plaque psoriasis of the lips: efficacy of combination therapy of topical tacrolimus, calcipotriol, and betamethasone dipropionate

A 16-year-old unmarried woman presented with recurrent cracking of the lips indicated by the appearance of grayish white flakes since October 2004, which, in due course, shed off leaving behind an apparently normal mucous membrane. Chewing roasted corn treated with salt and lemon (bhutta) initially caused the lesions. Ever since, it has been a cause of its exacerbation. She never had any relief with either systemic or topical treatment. In fact, an obsession had overtaken her, resulting in a psychological setback. She denied regular drug use for any other ailment. Her menstrual cycle was normal. There was a positive history of psoriasis in her mother. Examination of the lips was conspicuous. It was marked by the presence of a well-circumscribed, moist, raised plaque (Figure 1). Its surface was irregular, with elevation and depression. It was made up of thick, grayish white scales, which were arranged in layers; however, Grattage/Auspitz sign could not be elicited. Fissuring was prominent but the buccal mucosa, surface of the tongue, gingiva, and palate were normal. The clinical examination did not reveal any evidence of skin and/or nail psoriasis/psoriatic arthropathy or any other systemic abnormality. Blood examination including total and differential leukocyte count, complete hemogram, and liver and renal function tests were normal. Biopsy of the representative lesion was subjected to serial sections. They were stained with hematoxylin-eosin to work up microscopic pathology. It revealed the presence of mounds of parakeratosis with numerous neutrophilic Munro microabscesses (Figure 2). Submucosal vessels were dilated and congested. Periodic-acid-Schiff (PAS) stain revealed fungal hyphae and spores within the parakeratotic layer. Colonies of Gram-positive cocci were also demonstrated on the surface of the mucosa. She was administered combination therapy, comprising topical tacrolimus (0.1%) ointment and calcipotirol hydrate (50 microg/g) plus betmethasone dipropionate (0.5 mg/g) twice a day for 7 days. A single bolus dose of fluconazole 450 mg orally was also administered. The response to treatment was favorable and the lesions showed regression (Figure 3).

Oral manifestations of psoriasis. Clinical presentation and management

Psoriasis is a chronic immune-mediated disease of unknown etiology that affects the skin and mucous membranes. According to the National Institutes of Health (NIH), approximately five million Americans, 3% of the population, have been diagnosed with psoriasis. Oral manifestations of psoriasis are less well recognized than skin lesions, and treatment for oral lesions is not standardized. This article will review the clinical presentation of skin and mucous membrane psoriasis, along with the therapeutic modalities available to oral health-care providers.

Letter:Annular atrophic lichen planus of the lip

Annular atrophic lichen planus is a rare form of lichen planus, clinically characterized by a circumscribed annular configuration. We report herein a 32-year-old female who developed depressed plaques on the lips. Physical examination showed well-circumscribed, erythematous plaques on the lower lip. The border was slightly elevated and the inner portion was depressed and atrophic. Also, a bean-sized well-circumscribed plaque with slightly elevated border was found on the upper lip. A biopsy specimen revealed that the epithelium of the mucous membrane was reduced in thickness and a mononuclear cell infiltration invaded the basement membrane of the epithelium. This is the first case of annular atrophic lichen planus involving the lip. She was treated with 0.1 percent tacrolimus ointment once daily, which resulted in a beneficial effect.

Letter: Isolated annular lichen planus of lower lip

Lichen planus (LP), the prototype of lichenoid dermatoses, is an idiopathic inflammatory disease of the skin and mucous membranes, hair follicles, and nails. It rarely occurs on the lips and usually then in association with oral lesions. We report a 40-year-old man with a 3-month history of an isolated single annular violaceous plaque of the lower lip. The rest of his mucosae, skin, hair and nails were normal. Histopathology confirmed the diagnosis of LP. The patient was advised to use topical tacrolimus 0.03 percent cream twice daily along with multivitamins, but the patient was lost to follow-up. Isolated LP of the lip is unusual, although this condition may be underestimated and therefore under-reported in the literature.

Atypical case of oral lichen planus in a pediatric patient: clinical presentation and management

Lichen planus (LP) is a mucocutaneous disease of unknown etiology that is relatively common in adults but rarely present in childhood. LP has been documented in dental and medical literature; however, there are few cases with oral involvement in children. The purpose of this paper was to report an unusual case of oral lichen planus involving the upper lip in a 7-year-old girl. A diagnosis was made based on clinical examination and histopathology features. The treatment consisted of topical corticosteroid and intralesional injection. After treatment with an intralesional corticosteroid, a complete re- mission of lesions involving the lip was observed. The 3-year follow-up, however, revealed asymptomatic lichenoid bilaterally affecting the buccal mucosa. The patient is currently under regular review.

Orofacial granulomatosis of the lip: a report of 2 cases with histological and immunohistochemical analyses and intralesional corticotherapy

Orofacial granulomatosis is a generic term applied to manifestations of several diseases including sarcoidosis, Crohn's disease, Melkersson-Rosenthal syndrome, cheilitis granulomatosa of Miescher, tuberculosis and foreign-body reactions. What bonds these diseases together is the presence of noncaseating granulomas. A typical clinical manifestation of orofacial granulomatosis is recurrent labial swellings that eventually persist. This article describes 2 cases of OG diagnosed with the aid of immunohistochemical analysis and successfully treated with intralesional steroids.

[Swollen lip and cobblestone-like stomatitis in a young person--due to orofacial granulomatosis]

Chronic granulomatous inflammation of the mouth and the lip region is an increasing problem. Almost every second person with the disease will develop chronic bowel inflammation, thus exclusion of bowel inflammation by fecal testing is recommended. Topical tacrolimus or orally administered glucocorticoids, antibiotics and immunosuppressive drugs have been used in the treatment. The symptoms are typically variable, and visible changes to same extent persist for years. Diet has been suspected as the triggering factor, and some patients have benefited from benzoate and cinnamon-free diet.

Angiolymphoid hyperplasia with eosinophilia successfully treated with oral steroids

Angiolymphoid hyperplasia with eosinophilia is a rare benign vascular lesion most commonly affecting the head and neck region. This article reports a case of a 26-year-old white woman with rapidly enlarging nodules of the upper lip and cheek treated successfully with oral corticosteroids and cetirizine. Morbidity and cosmetic deformity associated with radical surgery to the face and possible consequences of radiation treatment were avoided. There were no long-term complications.

Perioral abscess associated with isotretinoin

Severe scarring acne is frequently treated with isotretinoin. Patients treated with this drug may expect some of the more common complications including mucositis. Less common complications may also occur in a small number of patients. While undergoing treatment, patients may become colonized with Staphylococcus bacteria. However, the incidence of perioral abscess formation in patients taking isotretinoin is not commonly reported and the onset of this adverse event may masquerade as angioedema or severe mucositis.This article presents a case of a significant perioral abscess and discuss the need for prompt recognition as well as treatment of the infection.The case reported is unique due to the extent and severity of the abscess.

[Mucosal complication of cutaneous leishmaniasis]

A 74-year-old man from the rural area of Caicedonia, Valle del Cauca Province, was diagnosed with uncontrolled hypertension, stage IV chronic renal failure and severe anemia. Fifteen years earlier, while living in Guaviare Province, he was diagnosed with leishmaniasis-with lesions located on the right upper and lower eyelids, left auricle and limbs. At that time, he received an incomplete treatment with antimonials. The patient had experienced 8 years of progressive mucosal lesions located in the upper lip, nasal mucosa and right upper and lower eyelids (figure 1). A histopathological diagnosis of leishmaniasis was made and confirmed by polymerase chain reaction (figure 2). Treatment with antimonials (Glucantime) was contraindicated due to the patient's comorbidities. Inpatient supervised treatment with miltefosine (Impavido 50 mg capsules) was initiated according to the national guidelines of 1.8 mg/kg/day for 28 days. Clinical follow up and routine laboratory tests (creatinine, BUN, liver function tests and complete blood counts) were done during and after treatment; no complications were reported. Medical follow up was continued until the Internal medicine, ophthalmology, and plastic surgery consultations were provided for subsequent management of the pathology. Mucocutaneous leishmaniasis is a serious preventable complication of cutaneous leishmaniasis. This case illustrated a failure in opportune diagnosis and treatment of this disease as a consequence of an inadequate leishmaniasis control program. The case indicated the effectiveness of miltefosine as a therapeutic option in patients for whom antimonial treatment is contraindicated.

Case report: leishmaniasis of the upper lip

We report a case of leishmaniasis localized to the upper lip in a 77-year-old Italian man. The disease was characterized by a severe swelling which involved the right side of the upper lip. The swelling was slightly erythematous with crusts and scaling. Consistency was parenchymatous-hard. The lesion was asymptomatic. Histopathologic examination showed an inflammatory infiltrate consisting of lymphocytes, histiocytes, and plasma cells. Several Leishmania spp. amastigotes were observed in the cytoplasm of macrophages. Cultural examination on Novy-MacNeal-Nicolle medium was positive for Leishmania spp. Polymerase chain reaction was positive for Leishmania infantum. The patient was treated with i.m. N-methylglucamine antimonate, with complete remission in approximately 6 weeks. During follow-up of 9 months, no relapses were observed.

Orofacial granulomatosis of the lower lip and cheek: report of a case

Orofacial granulomatosis (OFG) is a granulomatous disease of the orofacial region. This clinicopathological entity describes patients with oral lesions characterized by persistent and/or recurrent labial enlargement, ulcers, and a variety of other orofacial features, which on biopsy have lymphedema and noncaseating granulomas. The cause is idiopathic but appears to represent an abnormal immune reaction. This may be a manifestation of Crohn's disease (CD) since some patients with oral lesions develop typical bowel symptoms of CD in ensuing months to years; tooth-associated infections, sarcoidosis, food or contact allergies, and viruses have also been implicated in causing OFG. Clinical features of OFG are highly variable and sometimes so insidious that signs and symptoms are frequently not severe enough to cause alarm. The lips are most commonly involved and demonstrate a nontender, persistent swelling. Because of the relatively nonspecific clinical findings associated with granulomatous diseases, a microscopic diagnosis of granulomatous inflammation often presents a diagnostic dilemma for clinicians. We report a case of OFG of the lower lip and cheek and describe its management to add to the current body of literature on the subject.

Microbial-associated oral lichenoid reactions

OBJECTIVE

The objective of the present study was to compare a new type of symptomatic lichenoid reaction, specifically located on the mucosal side of the lips, and associated with microorganisms, with a matched group presenting with reticular oral lichen planus (OLP) of the buccal mucosa.

PATIENTS AND METHODS

The mean age for both groups was 66 years with a predominance of women (62%). The lichenoid reaction group (n = 25) presented with a reticular reaction pattern embracing various degrees of erythema. Patients presenting with OLP had similar lesions confined to the buccal mucosa but not on the mucosal side of the lips.

RESULTS

In both groups, 80% were on any type of medication. However, 56% of the patients with lichenoid reactions medicated with more than three drugs compared with 29% (P < 0.05) in the OLP group. The former group more often used medicaments prescribed for cardiovascular diseases (48%vs 25%). Twenty-two of the patients with lichenoid reactions were treated with chlorhexidine. In 80% of these patients (n = 18), the lesions improved or completely healed, indicating a microbial association.

CONCLUSION

Lichenoid reactions present on the mucosal side of the lips may be initiated by microbial plaque precipitated on the buccal surfaces of the anterior teeth.

A single-arm, open-label efficacy and tolerability study of diclofenac sodium 3% gel for the treatment of actinic keratosis of the upper and lower lip

OBJECTIVES AND METHODS

This study is an evaluation of patients diagnosed with actinic keratosis (AK) lesions of the upper and lower lip (both cutaneous and mucosal surfaces), with at least one lesion on the vermilion (mucosal) lip. Patients were treated twice daily with a topical application of diclofenac sodium 3% gel (Solaraze Gel, Doak Dermatologics) for a period of 90 days with a follow-up assessment at 30 days post-treatment. The presence or absence of target and new lesions was assessed and quantified at the initial baseline visit and at each follow-up visit. An investigator global improvement index score assessment and an evaluation of tolerability was also performed at each follow-up visit.

CONCLUSION

The application of diclofenac sodium 3% gel provides an effective approach for the treatment of AK of the lip. The cure rate reported in this study for AK of the lip was similar to that of diclofenac sodium 3% gel for AK on skin elsewhere on the body, and has a low incidence of irritation and other adverse reactions, as well as a high rate of patient satisfaction. The unique safety and tolerability profile of diclofenac sodium 3% gel would appear to lend itself well to treatment of the mucosal lip and vermilion, particularly when treatment decisions involve cosmetic appearance during and subsequent to therapy.

Peno-gingival lichen planus

BACKGROUND

Lichen planus with simultaneous oral and genital involvement in males is a quite rare condition and often difficult to diagnose. The prevalence, treatment options, and management for this condition are far from being established, and research in this area primarily relies on anecdotes. We present the clinical features of eight cases of peno-gingival lichen planus and propose a management algorithm for this condition based on the best available published evidence.

METHODS

Personal medical history was collected for all cases. Following careful examination of the oral and genital mucosae, pathology was obtained, previous treatments and duration of mucosal lesions ascertained, treatment initiated, and response evaluated at 8 weeks on both oral and genital lesions. The first-line drug was topical clobetasol propionate 0.05% cream in all cases; in case of failure, topical cyclosporin was used. A review of the literature on treatment options for this rare condition was performed based upon standard literature review practices.

RESULTS

Five cases presented gingival lesions that clinically resembled lichen planus. Glans penis was involved in all patients. All patients responded to treatment except for one. Oral candidiasis was the only observed side effect.

CONCLUSIONS

Genital lichen planus may be suspected in males when atrophic-erosive gingival lichen planus is found. A thorough multidisciplinary medical management and active early treatment are necessary to improve symptoms and prevent genital sequelae and, given the risk of squamous cell carcinoma, as a preventative strategy, although this area still needs investigation. Therapeutic trials relating to the treatment of peno-gingival lichen planus may be undertaken considering that current management relies exclusively on observations of case reports.

Perioral Angioedema Associated With Angiotensin-Converting Enzyme Inhibitor

BACKGROUND

Angioedema is a non-pruritic swelling usually limited to the skin and mucous membranes of the face and perioral soft tissues. It can be life threatening but usually is not, and can be managed with conservative medical treatment unless the airway is endangered. Recent reports suggest that angiotensin-converting enzyme (ACE) inhibitors can predispose and/or precipitate angioedema, with a predilection toward patients of African American ancestry.

METHODS

This case report involved a 65-year-old African American female who was being treated surgically for localized chronic periodontitis. The procedure was performed without incident, and the patient was alert and stable when released. The next day, the patient called and reported that her lips were swollen. She stated that this had happened a number of times over the past several years, sometimes related to eating shellfish and other times without any known precipitating factor. All previous episodes of perioral swelling occurred after ACE inhibitor therapy had been initiated.

RESULTS

The patient was in no distress, with no other site involvement. She was prescribed oral hydroxyzine and her appearance returned to normal after 5 days. Although the patient had experienced previous episodes of angioedema, none had been in response to any dental procedure. She was referred to the Allergy and Immunology Clinic for skin testing, the results of which were negative to shellfish with good controls. Other potentiating etiologies were also ruled out by the allergist.

CONCLUSIONS

Angioedema is a recognized possible side effect of ACE inhibitor therapy. The exact mechanism by which ACE inhibitors induce angioedema is not known, although the risk of occurrence is much greater in African Americans. Practitioners should be alert to this potentially fatal condition in patients who take ACE inhibitors or the newer angiotensin II receptor blockers (ARBs).

Intralesional interferon alfa-2b treatment of keratoacanthomas

BACKGROUND

Complete excision is not always easy when a keratoacanthoma is large or located in certain anatomic areas. An effective nonsurgical treatment would be desirable in such cases.

OBJECTIVE

This was a pilot study of the effects of intralesional interferon alfa-2b in the treatment of rapidly growing keratoacanthomas.

METHODS

A total of 4 large, rapidly growing keratoacanthomas, which were located on the lower lip, neck, and cheeks of the 4 different patients, were treated with intralesional interferon alfa-2b injection weekly. Serial photographs were taken to observe the course of responses.

RESULTS

All lesions resolved completely in 5 to 7 weeks with acceptable cosmetic results.

CONCLUSION

Intralesional interferon alfa-2b can be a treatment modality of these difficult lesions.

Orofacial granulomatosis presenting as persistent lip swelling: review of 6 new cases

PURPOSE

Orofacial granulomatosis (OFG) is an uncommon disease, which presents usually as a persistent swelling of the soft tissues in the orofacial region and is characterized histologically by a granulomatous inflammation. The term orofacial granulomatosis is used in the literature to describe a nonspecific granulomatous inflammation. A subset, cheilitis granulomatosa (CG), which presents clinically as persistent lip swelling, is a granulomatous inflammation of unknown origin of the lips. CG may also be part of the triad of the Melkersson-Rosenthal syndrome (MRS) and some consider it as an oligosymptomatic form of MRS.

PATIENTS AND METHODS

In a retrospective study, we reviewed the clinical records of all patients between the years 1990 and 2002 with the histologic diagnosis of granulomatous inflammation of the lip from the Department of Pathology at the Montreal General Hospital. The age at biopsy, sex, site of lesion, other signs of MRS, signs and symptoms of systemic granulomatous disease, and the treatment were compiled.

RESULTS

Six subjects were included in the study, 5 females and 1 male. Four had swelling of the lower lip and 2 of the upper lip. In one patient a history of facial nerve palsy was reported and in another one a mild fissured tongue was present. No signs or symptoms of systemic granulomatous disease were noted. The treatment consisted of intralesional steroids with good results in 5 out of 6 patients.

CONCLUSION

A thorough work-up to eliminate other etiologies of granulomatous disease is essential when a patient presents with granulomatous inflammation of the lip. CG seems to respond well to steroid treatment and the need for surgery is minimal and should be reserved for recalcitrant cases.

Leishmaniasis of the lip in a patient with Down's syndrome

Cutaneous leishmaniasis is an endemic protozoan infection in Sardinia, one of the major islands of the Mediterranean Basin. The main causative strain in this country is Leishmania infantum, which rarely involves mucocutaneous areas, but has the potential to cause visceral leishmaniasis. An atypical leishmaniasis involving the inferior lip of a 57-year-old female with Down's syndrome was observed at the Dermatology Department of Cagliari (italy). The diagnosis was mainly based upon histopathological examination, revealing intra- and extra-cellular leishmania amastigotes. The leishmania infantum zymodeme MON-111 was identified by isoenzymatic characterization. Laboratory investigations revealed a normal complete blood count and biochemistry profile, except for an inverted CD4/CD8 ratio. Treatment with meglumine antimoniate 60 mg/kg/day (Glucantime) intramuscularly for 15 days, followed by intralesional administration 1 ml weekly for 4 weeks led to complete recovery. No relapses were observed at 6-month follow-up. The unusual localization is likely to be a reflection of the uncommon site of inoculation of the protozoa, transmitted by bites from flying vectors. Nevertheless, the presence of Down's syndrome in our patient may have contributed to the atypical presentation by traumatic exacerbation of the lesion, due to repeated auto-induced microtraumas of the inferior lip accompanied by subclinical immunodeficiency. In fact, the specific immune response to Leishmania infection depends on a host-cell-mediated immune response, reported as defective in Down's syndrome patients. Differential diagnosis and early detection of the infection are necessary in order to start effective treatment and prevent more serious complications.

Oral myiasis treated with ivermectin: case report

Oral myiasis is a rare pathology and a risk to the patient's life. Conventional treatment is mechanical removal of the larvae (maggots) one by one, which is painful, distressing, and embarrassing both to the patient and to the dentist. We present a case report of a patient with cerebral palsy that had oral myiasis treated successfully with ivermectin. The use of this antibiotic in humans, its mechanism of action and indications are discussed.

[Diagnostic image (185). A man with a pimple on the upper lip. Carbuncle of the upper lip]

A 24-year-old man presented with a carbuncle of the upper lip. Surgical drainage was installed and flucloxacillin was administered. Full recovery ensued. In culture Staphylococcus aureus was abundant.

Chronic disseminated histoplasmosis in an apparently immuno-competent Belgian patient

A 77 year-old Belgian man was admitted for weight loss and elevated liver enzymes. He used to live in Central Africa until 1986 and denied any travel outside Belgium during the last decade. Physical examination was unremarkable except for a lip ulceration. Blood tests showed increases of liver enzymes and CEA. In the search of an abdominal cancer, CT showed a normal liver but enlarged surrenal glands, while colonoscopy disclosed multiple mucosal lesions. Colic and lip biopsies identified Histoplasma capsulatum var capsulatum. HIV serology was negative. Lymphocyte count was normal but lymphocyte function was depressed. The patient dramatically improved under oral treatment with Itraconazole 400 mg daily for six months. This case indicates that chronic disseminated Histoplasmosis can reactivate in a healthy and apparently non-immunocompromised person living in Europe.

Systemic acyclovir reaction subsequent to acyclovir contact allergy: which systemic antiviral drug should then be used?

Allergic contact dermatitis caused by acyclovir is rare. We report the 5th case of systemic acyclovir reaction subsequent to acyclovir contact dermatitis, with investigations made to determine an alternative antiviral treatment. A 23-year-old woman, after dermatitis while using Zovirax cream, went on to develop urticaria after oral acyclovir. Patch tests were performed with the components of Zovirax cream (acyclovir, propylene glycol and sodium lauryl sulfate) and with other antiviral drugs. Patch tests were positive to Zovirax cream, acyclovir, valacyclovir and propylene glycol. Patch and prick tests with famciclovir were negative, but its oral administration caused an itchy erythematous dermatitis on the trunk and extremities. Our patient developed a systemic acyclovir reaction subsequent to acyclovir allergic contact dermatitis, with cross-reactions to valacyclovir and famciclovir. Their common chemical structure is the 2-aminopurine nucleus. It is probably this part of the molecule that provokes both contact allergy and systemic reactions. The only antiviral drugs not having this core are foscarnet and cidofovir, and these could therefore be alternatives.

[Mechanisms disordering wound healing on the lip after bilateral crossing of the inferior alveolar nerve and experimental validation of correction methods]

The mechanisms of lip wound healing after bilateral crossing of the inferior alveolar nerve (IAN) were studied on Chinchilla rabbits in 3 experimental series, 6 animals per series. In group 1 bilateral crossing of IAN was carried out, in group 2 bilateral crossing of IAN was paralleled by removal of a mucous flap in the middle of the lower lip, and in group 3 the same wound as in group 2 was created, after which the wounds in this group were daily treated with a special ointment and a single injection of lidocaine (1% solution) under the wound. The nerve crossing led to development of ulcer on the lip with degenerative changes in the vascular walls, destruction of nerve fibers, and fragmentation of some axial cylinders. Crossing of IAN simultaneously with removal of the lower lip flap led to more severe degenerative changes in the tissue. Daily treatment of the lip with the ointment and lidocaine blocking normalized wound healing. A possible mechanism of the changes observed is discussed.

A review of common pediatric lip lesions: herpes simplex/recurrent herpes labialis, impetigo, mucoceles, and hemangiomas

Lip lesions are a common presentation to the pediatrician's office. These lesions are often benign in children, without significant functional morbidity. However, owing to the prominent placement of lips and their role in communication, lip lesions can be alarming to patients as well as to their parents. For these reasons the pediatrician has an important role in recognizing, diagnosing, and treating the various types of labial dermatoses that commonly present to a pediatric practice. Four of the most common lip lesions a pediatrician will see are herpes simplex/recurrent herpes labialis, impetigo, mucoceles, and hemangiomas. This paper reviews the current literature on the diagnosis, treatment, and management of these 4 lesions.

Effects of a betaine-containing toothpaste on subjective symptoms of dry mouth: a randomized clinical trial

Our aim was to study the effects of mildly flavoured sodium lauryl sulphate (SLS)-containing and detergent-free toothpastes with and without betaine (BET) on subjective symptoms of dry mouth in a randomised clinical trial. BET is an osmoprotectant that reacts with molecules to supply the surface with a water coating that protects cells from surfactants. Twenty-seven xerostomic patients and 18 healthy controls took part in the randomised, double-blind clinical trial with a crossover design. Three mildly flavoured toothpastes: (1) 4% BET, (2) 1% SLS and 4% BET, and (3) 1% SLS were used for six weeks each. The reference or washout paste contained neither SLS nor BET. The subjects' dental appointments were at the beginning of the trial and before and after the use of each toothpaste. At each appointment, the subjects were interviewed about subjective sensations of dry mouth (Visual Assessment Scoring (VAS) Index). The subjects did not report any adverse effects in connection with the use of the toothpastes. The VAS scores for lip dryness and eating difficulties were significantly lower for the BET paste (lip dryness: BET<BET+SLS; p < 0.005 and eating difficulties: BET<BET+SLS; p = 0.02; BET<reference; p = 0.003). The BET paste relieved dry mouth symptoms in 44% of the xerostomic patients, the corresponding figures for the other pastes being BET+SLS 22% (p = 0.002 as compared with BET), SLS 18% (p = 0.022), and reference 7% (p = 0.000). In conclusion, all the mildly flavoured toothpastes used in this study were well accepted by the xerostomic subjects. Thus, other toothpaste components may be more mucosa-irritating than just SLS, or else they enhance the effect of SLS. The detergent-free, BET-containing toothpaste appeared to be associated with relief of some symptoms of dry mouth.

Thalidomide for the treatment of recalcitrant oral Crohn's disease and orofacial granulomatosis

It has been suggested that thalidomide may be effective in the management of Crohn's disease, including the associated oral lesions. We detail the clinical response to low-dose thalidomide of 5 patients with clinical features of orofacial granulomatosis or oral Crohn's disease recalcitrant to recognized immunosuppressant therapy. All patients had clinical resolution of their symptoms and signs. Transient somnolence was the only reported adverse effect. Remission was maintained by extending the period between thalidomide doses. Thalidomide should be considered an effective therapy for the short-term treatment of severe orofacial granulomatosis in appropriately counseled patients.

Lip silicone granulomatous foreign body reaction treated with aldara (imiquimod 5%)

We report a case of a lip granulomatous reaction after injection of silicone being treated successfully with topical Aldara (Imiquimod 5%). Silicone granulomas and the inflammatory foreign body reaction that can occur are some of the complications that arise from using silicone for cosmetic enhancement. The inflammatory reaction of this patient first appeared shortly after silicone injection of both the upper and lower lips. Histopathologic examination revealed a foreign body inflammatory reaction that is consistent with silicone granuloma. Although this reaction has been described extensively in the dermatologic literature as one of the disfiguring side effects of silicone injection, its treatment has plagued cosmetic dermatologists. We report the use of an immunomodulatory cream Aldara (Imiquimod 5%) to treat this type of reaction.

Persistent acantholytic dermatosis of the lip related to solar damage

We describe the case of a 70-year-old woman with persistent acantholytic dermatosis. The peculiarity of the case lies in the unusual localization of this dermatosis on the lower lip. A possible relationship with chronic solar damage is discussed.

Acute streptococcal infection of the gingiva, lower lip, and pharynx--a case report

BACKGROUND

Streptococcal gingivostomatitis is a rare phenomenon in a non-compromised host and not commonly reported in the dental literature. Early diagnosis and distinction from viral infections, especially HSV infection, are of the utmost importance. The early use of penicillin is essential in preventing a cascade of events, resulting in severe fasciitis, destruction of tissues, and subsequent rheumatic fever and rheumatic heart disease.

METHODS

A unique case of group A beta-hemolytic streptococcal infection affecting the pharynx, lower lip, and gingiva of a healthy 19-year-old male is presented.

RESULTS

The streptococcal infection was responsive to penicillin treatment.

CONCLUSIONS

In view of the increased use of antibiotics and the development of aggressive strains, the dental clinician has to consider streptococcal infection in the differential diagnosis of gingival and soft tissue infections.

Labial tuberculosis: a unique cause of lip swelling complicating HIV infection

BACKGROUND

HIV disease has many oral manifestations including tuberculosis, which most commonly presents as irregular ulceration of the tongue or the palate. We detail an HIV-infected patient found to have tuberculosis of the lip.

CONCLUSIONS

To our knowledge tuberculosis of the lips has never been reported in conjunction with HIV infection, and in this case establishing the oral diagnosis resulted in the diagnosis of disseminated disease.