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Erythematous Burning Lips

Case Challenge Number: 26

Diagnostic Information

History of Present Illness The patient is a dental hygienist who reported her symptoms began four weeks prior to clinical examination. She had been treated with acyclovir for two days, followed by a six day, tapering course of methylprednisolone, both of which provided mild temporary relief of her symptoms. Additionally, she had been liberally applying several different types of over-the-counter lip balms and moisturizers several times a day since the initial onset of symptoms. She denied any prior episodes. The patient reported one of the two different dental offices where she worked had recently switched to a new brand of disposable surgical masks.

Past Medical History The patient is an otherwise healthy 33-year-old female who is taking cetirizine HCl for hay fever and has allergies to penicillin and codeine. She had recently been diagnosed with a vaginal yeast infection by her gynecologist and was prescribed miconazole. The yeast infection resolved uneventfully. Clinical Findings The patient is a 33-year-old female who was in distress, stating her lips were extremely sore and felt like they were burning. Extraoral examination revealed swollen, erythematous upper and lower lips with surrounding erythema extending 2-6 mm beyond the vermilion border onto the perioral skin. (Figure 1) A yellow crusted film was observed diffusely across the lips and the perioral skin, and could be partially scraped away. Microfissures were located in multiple areas, including the vermilion zone, and bled easily when the lips were stretched. The patient reported mild tenderness upon palpation of the submandibular nodal region, but no adenopathy was palpable. Intraoral examination revealed no significant findings, and all tissues appeared pink and healthy. No other skin lesions were reported or identified.

Case Challenge 26 - Content - Select Diagnosis - Figure 1

Figure 1. Swollen, erythematous lips and perioral skin with overlying yellow crusts.

Cytology and Photomicrographs A cytologic smear was performed at the time of examination. The slide was stained with the periodic acid-Schiff (PAS) method. Microscopic examination revealed an adequate sampling of keratinocytes and colonization with fungal hyphal organisms. (Figures 2 and 3)

Case Challenge 26 - Content - Diagnostic Information - fig02-photomicrograph-med

Figure 2. A medium power photomicrograph depicting a cytologic smear with keratinocytes, ovoid yeasts, and branching, tubular-appearing hyphae. (Periodic acid-Schiff stain, original magnification 200x)

Case Challenge 26 - Content - Diagnostic Information - Figure 3

Figure 3. A high power photomicrograph depicting a cytologic smear with easily identifiable, bright magenta, tubular-appearing hyphae, and ovoid yeasts. (Periodic acid-Schiff stain, original magnification 400x)