This article is more than 5 years old. Information may no longer be current.
7-year-old boy presents with facial rash
Click Here to Manage Email Alerts
A 7-year-old healthy male presented to the dermatology clinic for evaluation of a facial rash. The rash had been happening off and on over the last few years. It is most notable during the winter. He reported mild burning and itching at the site of the rash (Figure 1). His parents had tried multiple lip balms, shea butter and Aquaphor with varying levels of improvement. Coconut oil made it worse.
He did not have a history of atopic dermatitis or other skin problems. He did have a history of mild intermittent asthma and took albuterol as needed. On exam, there was a sharply demarcated pink eczematous plaque around the lower lip extending on to the vermilion border. Other than generalized dry skin, there were no other rashes noted on full body skin examination. During the visit the patient was witnessed licking his lips a few times.
Can you spot the rash?
A. Lip licker’s dermatitis
B. Periorificial dermatitis
C. Psoriasis
D. Allergic contact dermatitis
E. Atopic dermatitis
Lip licker’s dermatitis is a form of chronic irritant contact dermatitis from saliva (choice A). It is common in children but can also be seen in adults. The condition often begins in the fall or winter with dry lips that the patient licks. Licking causes temporary relief, but the saliva ultimately irritates the lips and surrounding skin. This creates a vicious circle of licking and worsening irritation, which often becomes a habit that is difficult to break. Over time, well-demarcated, eczematous plaques form over the areas of skin the tongue can reach. Lichenification and hyperpigmentation may occur in more severe or prolonged cases. It is important to ask the patient to show you how they lick their lips because some children lick with their tongue, but many children also use one lip to lick the other by placing the bottom lip directly over the top lip or vice versa.
Treatment focuses on protecting the underlying skin and breaking the licking habit. Frequent application of a barrier such as petroleum jelly multiple times throughout the day helps to shield the skin from saliva and encourage healing. In more severe cases, low-potency topical steroids or topical calcineurin inhibitors may be used twice daily for 1 to 2 weeks. Once the dermatitis is resolved, continued application of bland emollients one to two times a day is recommended to prevent recurrence.
Periorificial dermatitis, sometimes just called perioral dermatitis, is another condition that can cause a rash around the mouth. Although the exact pathogenesis is not known, it is seen more frequently in patients who use inhaled corticosteroids or mid- to high-potency topical steroids in the affected area. Discrete erythematous papules and papulopustules concentrate in a perioral, perinasal and periocular distribution. Diffuse erythema and scaling may be left behind as the papules resolve. The area around the vermilion border is typically spared, unlike lip licker’s dermatitis, in which the lips and vermilion border are affected. Topical steroids may result in temporary improvement but ultimately exacerbate the condition.
Allergic contact dermatitis is less common than irritant contact dermatitis but is important to consider in the differential diagnosis of perioral rashes in children. Allergic contact dermatitis is typically very pruritic and more inflamed, whereas irritant contact dermatitis may have mild itching or more burning. Common culprits that can produce symptoms that mimic lip licker’s dermatitis include mangos (related to poison ivy allergy) and ingredients in toothpastes, topical products and wet wipes. Patch testing can be helpful in identifying a causative allergen.
Atopic dermatitis is a chronic skin condition with pruritic papules and plaques related to a defective skin barrier and inflammation. It typically presents in early infancy, although it may develop later in childhood in some cases. Associated atopic conditions include asthma, allergic rhinitis and food allergies. Patients with atopic dermatitis may be more prone to developing irritant contact dermatitis. In this patient, the lack of skin findings in characteristic areas, such as posterior neck, popliteal fossae and antecubital fossae and no history of other rashes, is helpful in ruling out atopic dermatitis.
Psoriasis is another chronic inflammatory skin condition that can be seen in childhood, although less commonly than atopic dermatitis. It is characterized by pink- or salmon-colored, well-demarcated plaques with thick scales, usually found on the extensor elbows, knees, umbilicus and scalp in the most common form, known as plaque psoriasis. Facial lesions are more common in pediatric patients. The thinner eczematous scale, along with classic history and physical exam. can help to distinguish lip licker’s dermatitis from psoriasis.
When examining a chronic, scaling rash around the mouth, vermillion border involvement is often a clue to lip licker’s dermatitis. Ask the patient to demonstrate how they lick their lips, and it will often lead you to the diagnosis if the licking matches the area of skin involved.
- For more information:
- Colleen H. Cotton, MD, is a pediatric dermatology fellow at The Children’s Hospital of Philadelphia. She can be reached at cottonch@email.chop.edu.
- Marissa J. Perman, MD, is an attending physician at The Children’s Hospital of Philadelphia.
Disclosures: Cotton and Perman report no relevant financial disclosures.