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Collagen implant in management of perléche (angular cheilosis)
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Collagen implant in management of perl6che (angular cheilosis) Marvin E. Chernosky, M.D., Houston, TX Perl6che (angular cheilosis) is often caused by the presence of saliva on skin adjacent to mucous membranes. In some cases saliva escapes from the mouth through deep grooves that extend inferolateraUy from oral commissures. If the sulci are secondary to a decreased vertical dimension of the lower one third of the face (determined by described measurements), corrective dental measures may be curative. When this approach is not practical and in other cases when the grooves are produced by other causes, the defects can be corrected by use of injections of collagen implant. This has been done successfully in two patients, and angular cheilosis has not reoccurred. (J AM AC.ADDERMATOL12:493-496, 1985.)
Angular cheilosis, or perl6che, a moist form of intertrigo at the oral commissures, is commonly seen in patients, although many do not complain about the problem when its presentation is minimal. Although vitamin deficiencies, allergic contact dermatitis, and primary infections with bacteria or Candida albicans have been etiologically incriminated, the presence of excessive saliva on skin adjacent to labial mucous membranes seems to be the most important factor in most cases. 1.2 Saliva artificially wets the skin, causing swelling of stratum corneum. This superhydration alternates with episodes of desiccation caused by ambient low humidity and increased wind velocity accompanying natural weather changes or manmade indoor winter or summer environments. The alternating swelling and shrinking result in cellular damage 3 manifested clinically by chaps, fissures, erythema, exudation, and secondary infections.* Saliva at the comers of the mouth results from One or more of the following conditions: From the Department of Dermatology, University of Texas Medical School at Houston. Accepted for publication Oct. 8, 1984. No reprints available, *Chernosky ME: Clinical aspects of dry skin. J Soc Cosrnet Chem 27:365-376, 1976.
1. Mouth breathing secondary to nasal congestion or dental malocclusion (anterior open bite with labioversion of teeth) may result in drooling of saliva, especially during sleep. Because sleeping habits frequently cause one side of the face to be in a dependent position more often, the angular cheilosis may be unilateral. 2. The compulsive habit of licking the comers of the mouth sometimes causes angular cheilosis. Early French observers were aware of this, and thence comes the name perldche, which literally means "to lick one's lips." 3. A groove caused by excessive inward folding of skin at the angles of the mouth may become an escape route for saliva leaving the oral cavity and oozing onto adjacent skin. These sulci extending inferolaterally from the corners of the mouth may be congenital in nature, because they have been observed in young people. More often they are acquired later in life because of sagging of the soft facial tissues related to aging or weight loss or both. Another cause is an abnormal decreased vertical dimension of the lower one third of the face, 2 caused by worn or eroded teeth, loss of teeth, or resorption of alveolar bone following teeth extraction. In patients with marked decreased dimension, the mouth assumes a slitlike horizontal 493
Journal of the 494
American Academy of Dermatology
Chernosky
Fig. 1. Perl~che in patient with decreased vertical dimension of lower one third of face. The rima otis (parting line of the lips) is flattened horizontally, exposed portions of vermilion borders are decreased, and grooves extend inferolaterally from oral commissures. appearance, with a decrease in exposed portions of the vermilion borders, especially the superior one (Fig. 1). These anatomi c changes may not be observable in patients with lesser degrees of decreased dimension. A simple technic to quantitate a decreased vertical facial dimension has been described. A Willis bite gauge* is used, although a millimeter ruler and tongue blade Can be used. 2 The patient is requested to stare in the area of the glabella of the person taking the measurements. The patient is requested to relax, to say "one, two, three," to swallow, to place the teeth together gently in normal occlusal contact, and then not to move the mandible. Distance A extends from the center of the pupil of the eye to the rima otis, or parting line of the lips (Fig. 2). Distance B is measured from the base of the nose to the lower edge of the mandible, as felt through soft tissues (Fig. 3). According to previous studies, 2 a patient is classified as having a decreased vertical dimension of the lower one third of the face if distance B is 6 mm or more shorter than distance A. Having determined a significant decrease in vertical facial dimension in a patient, on certain occasions a general dentist or prosthodontist can correct this loss (see second paragraph under "Corn*WillisFM: Featuresof the face involvedin fall dentureprosthesis. Dent Cosmos77:851-854, 1935,
Fig. 2. Measurement of distance A. merit"). In many instances, however, these dental manipulations are not feasible. A more direct approach, the filling in of these grooves With collagen implant, has recently been used in two patients.
CASE REPORTS Case 1 A 55-year-old woman came to the office complaining that saliva was leaking from the comers of her mouth. Intermittently she had bilateral ped~che manifested by exudation, crusting, erythema, and fissuring. A decreased vertical facial dimension was demonstrated (distance A = 70 ram, B = 60 ram). Treatment with a broad-spectrum antimicrobial topical preparation in a protective ointment base (Mycolog Ointment) cleared the condition temporarily, but it reoccurred following discontinuation of the medicine. After the necessary history was taken and the intradermal and subcutaneous skin test was used as specified in the manufacturer's drug insert,* purified bovine *Zydenn Collagen Implant Physician Package Insert. June, 1983, Palo Alto, CA, CollagenCorp.
Volume 12 Number 3 March, 1985
Collagen implant in perl~che 495
Fig. 4. Patient 1, with inward foldings of skin extending inferolateral!y from corners of mouth. Angular eheilosis has been suppressed: by topical medication.
Fig. 3. Measurement of distance B. collagen implant (Zyderm) was injected into the depths of the grooves during nine different office visits in a 6month period. A total of two vials of Zyderm I and half of a vial of Zyderm II were used. Fig. 4 shows the patient prior to the injections, and Fig. 5 was taken 8 months later. Saliva no longer escapes from oral commissures, and angular cheilosis has not reoccurred during 8 months of posttreatment observations. Case 2 A 32-year-ol d man came to the office Complaining of persistent and irritating dermatitis of the left oral commissure for many months. More recently he developed the sam e problem in the riglit oral commissure. Vertical facial dimensions were decreased (A = 72 mm, B = 62 mm). Examination revealed a decrease in the height of the teeth, probably secondary to bruxism. Following the manufacturer's instructions preliminary to the use of Collagen implant, a total of two vials of Zyderrn I have been used in the oral commissures on three occasions over a period of 2 months. The depth of the sulci have been decreased, and during 3 months of posttreatment observation angular cheilosis has not reoccurred.
Fig. S. Patient 1. Photograph was taken 8 months after Fig. 4 and 2 months after completion Of collagen implantation of sulci extending from 0ral commissures.
COMMENT The prescribing of vitamins and the search for allergic contact dermatitis often are not helpful in the management of angular cheilosis. Topical broad-spectrum antimicrobial agents in ointment base (to shield the skin from saliva) are beneficial. However, if saliva continues to escape in soft tissue sulci extending inferolaterally from the corners of the mouth, signs and symptoms will persistently reoccur. If the sulci are secondary to decreased vertical dimension of the lower one third Of the face, some patients can be helped by capping worn or eroded teeth, replacing lost teeth, or increasing the height of dentures to compensate for alveolar bone re-
496
Journal of the American Acad6my of Dermatology
Chernosky
sorption. 4'5 In m a n y patients, however, the dentist m a y choose not to increase this vertical dimension because of other important factors such as improper function of the temporomandibular joint, premature striking o f the teeth, phonetics, and the patient's overall comfort and appearance. A more direct approach to decreasing the depth o f the grooves angling from the comers of the mouth has been undertaken by using injectable collagen implant. In two patients this approach has b e e n successful and angular cheilosis has not recurred. Long-term posttreatment observations are not yet available, but additional injections of collagen implant will probably be required. Injectable collagen implant has been used successfuUy primarily to improve the appearance of scars and facial wrinkles. 6 The treatment of angular cheilosis must b e added to the list of indications for its use.
ADDENDUM The two patients described were followed for an additional 3-month period. There has been no recurrence of perl~che nor need for further treatment.
REFERENCES 1. Chernosky ME: Dental conditions of diagnostic aid in mucocutaneous medicine. Arch Dermatol 84:115-122, 1961 2. Chernosky ME: Relationship between vertical facial dimension and perl~ehe. Arch Dermatol 93:332-337, 1966, 3. Chemosky ME: Dry skin and its consequences. J Am IVied Wom Assoc 27:133-142, 145, 1972. 4. Swenson MG: Complete dentures, St. Louis, 1940, The C. V. Mosby CO., p. 655, 5. Spies TD, Mann AW, Springer FM: Preliminary report on the effect of mechanical increase in the vertical dimension of the face in angular cheilosis. J Dent Res 21:305-306, 1942. 6. Castrow FF, Krull EA: Injectable collagen implant--update. J AM ACADDERMATOL9:889-8932 1983.
ABSTRACTS Skin penetration of benzoyl peroxide (German text) Seubert S, Seubert A, Ippen I-I: Hautarzt 35:455-458, 1984 The benzoyl peroxide content of abraded horny layer and its metabolite benzoic acid were examined by high-pressure liquid chromatography after 1 to 2 minutes application of an emulsion containing benzoyl peroxide. Benzoylperoxide penetrates the horny layer very quickly and is rapidly changed into benzoic acid. A depot of benzoyI peroxide could not be found in the horny layer. No depot formation is necessary for the therapeuticeffect of benzoyl peroxide since within 2 hours after its use a strong bacterial reduction occurs.
Alfred Hollander. M.D.
drawal, relapses occurred after 3 to 18 months, The effective mechanism is yet unknown.
Alfred Hollander, M.D.
Porphyria cutanea tarda and chronic lymphatic leukemia (German text) Montag H, Schmeel A: Z Hautkr 59:1372-1376, 1984 A 58-year-old patient had porphyria cutanea tarda that was diagnosed in August 1983. Enlarged lymph nodes of the axillary and inguinal regions existed for at least 10 years. Other lymph nodes enlarged recently. Histologically, chronic lymphatic leukemia was found. In this case, as in two other similar cases in the literature, it is assumed that the lymphoma triggered the development of porphyria cutanea tarda.
Cheilitis granulomatosa (Melkersson-Rosenthal syndrome): Treatment with clofazimine (German
Alfred Hollander, M.D.
text)
Camouflage therapy
Neuhofer J, Frisch P: Hautarzt 35:459-463, 1984
Downie, M: Australas J Dermatol 25:89-91, 1984
Seven patients with cheilitis granulomatosa, three of them with completeMelkerss0n-Rosenthal syndrome, were treated with the leprostatic agent clofazimine, 100 mg daily for I0 days; thereafter, they were treated with 100 mg 2 to 4 times weekly for 2 to 12 months. The treatment response of the swelling of the lips was generally favorable. Some persistent residual swelling responded only incompletely. The therapeutic influenceon lingua plicata and facial paresis could not be judged from these few observations. After drug with-
Three camouflage cosmetics (Dermacolor, West Germany; Covermark, Lydia O'Leary; and Keromask, Innoxa) were compared in thirty-one patients with a variety of disfiguring lesions. Of eleven vitiligo patients, six preferred Dermacolor and five, Covermark. Of the variety of other lesions, ineluding hemangiomas, scarring, keloids, telangiectasia, ere., Dermacolor was preferred.
J.G.S.
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Collagen implant in management of perl6che (angular cheilosis) Marvin E. Chernosky, M.D., Houston, TX Perl6che (angular cheilosis) is often caused by the presence of saliva on skin adjacent to mucous membranes. In some cases saliva escapes from the mouth through deep grooves that extend inferolateraUy from oral commissures. If the sulci are secondary to a decreased vertical dimension of the lower one third of the face (determined by described measurements), corrective dental measures may be curative. When this approach is not practical and in other cases when the grooves are produced by other causes, the defects can be corrected by use of injections of collagen implant. This has been done successfully in two patients, and angular cheilosis has not reoccurred. (J AM AC.ADDERMATOL12:493-496, 1985.)
Angular cheilosis, or perl6che, a moist form of intertrigo at the oral commissures, is commonly seen in patients, although many do not complain about the problem when its presentation is minimal. Although vitamin deficiencies, allergic contact dermatitis, and primary infections with bacteria or Candida albicans have been etiologically incriminated, the presence of excessive saliva on skin adjacent to labial mucous membranes seems to be the most important factor in most cases. 1.2 Saliva artificially wets the skin, causing swelling of stratum corneum. This superhydration alternates with episodes of desiccation caused by ambient low humidity and increased wind velocity accompanying natural weather changes or manmade indoor winter or summer environments. The alternating swelling and shrinking result in cellular damage 3 manifested clinically by chaps, fissures, erythema, exudation, and secondary infections.* Saliva at the comers of the mouth results from One or more of the following conditions: From the Department of Dermatology, University of Texas Medical School at Houston. Accepted for publication Oct. 8, 1984. No reprints available, *Chernosky ME: Clinical aspects of dry skin. J Soc Cosrnet Chem 27:365-376, 1976.
1. Mouth breathing secondary to nasal congestion or dental malocclusion (anterior open bite with labioversion of teeth) may result in drooling of saliva, especially during sleep. Because sleeping habits frequently cause one side of the face to be in a dependent position more often, the angular cheilosis may be unilateral. 2. The compulsive habit of licking the comers of the mouth sometimes causes angular cheilosis. Early French observers were aware of this, and thence comes the name perldche, which literally means "to lick one's lips." 3. A groove caused by excessive inward folding of skin at the angles of the mouth may become an escape route for saliva leaving the oral cavity and oozing onto adjacent skin. These sulci extending inferolaterally from the corners of the mouth may be congenital in nature, because they have been observed in young people. More often they are acquired later in life because of sagging of the soft facial tissues related to aging or weight loss or both. Another cause is an abnormal decreased vertical dimension of the lower one third of the face, 2 caused by worn or eroded teeth, loss of teeth, or resorption of alveolar bone following teeth extraction. In patients with marked decreased dimension, the mouth assumes a slitlike horizontal 493
Journal of the 494
American Academy of Dermatology
Chernosky
Fig. 1. Perl~che in patient with decreased vertical dimension of lower one third of face. The rima otis (parting line of the lips) is flattened horizontally, exposed portions of vermilion borders are decreased, and grooves extend inferolaterally from oral commissures. appearance, with a decrease in exposed portions of the vermilion borders, especially the superior one (Fig. 1). These anatomi c changes may not be observable in patients with lesser degrees of decreased dimension. A simple technic to quantitate a decreased vertical facial dimension has been described. A Willis bite gauge* is used, although a millimeter ruler and tongue blade Can be used. 2 The patient is requested to stare in the area of the glabella of the person taking the measurements. The patient is requested to relax, to say "one, two, three," to swallow, to place the teeth together gently in normal occlusal contact, and then not to move the mandible. Distance A extends from the center of the pupil of the eye to the rima otis, or parting line of the lips (Fig. 2). Distance B is measured from the base of the nose to the lower edge of the mandible, as felt through soft tissues (Fig. 3). According to previous studies, 2 a patient is classified as having a decreased vertical dimension of the lower one third of the face if distance B is 6 mm or more shorter than distance A. Having determined a significant decrease in vertical facial dimension in a patient, on certain occasions a general dentist or prosthodontist can correct this loss (see second paragraph under "Corn*WillisFM: Featuresof the face involvedin fall dentureprosthesis. Dent Cosmos77:851-854, 1935,
Fig. 2. Measurement of distance A. merit"). In many instances, however, these dental manipulations are not feasible. A more direct approach, the filling in of these grooves With collagen implant, has recently been used in two patients.
CASE REPORTS Case 1 A 55-year-old woman came to the office complaining that saliva was leaking from the comers of her mouth. Intermittently she had bilateral ped~che manifested by exudation, crusting, erythema, and fissuring. A decreased vertical facial dimension was demonstrated (distance A = 70 ram, B = 60 ram). Treatment with a broad-spectrum antimicrobial topical preparation in a protective ointment base (Mycolog Ointment) cleared the condition temporarily, but it reoccurred following discontinuation of the medicine. After the necessary history was taken and the intradermal and subcutaneous skin test was used as specified in the manufacturer's drug insert,* purified bovine *Zydenn Collagen Implant Physician Package Insert. June, 1983, Palo Alto, CA, CollagenCorp.
Volume 12 Number 3 March, 1985
Collagen implant in perl~che 495
Fig. 4. Patient 1, with inward foldings of skin extending inferolateral!y from corners of mouth. Angular eheilosis has been suppressed: by topical medication.
Fig. 3. Measurement of distance B. collagen implant (Zyderm) was injected into the depths of the grooves during nine different office visits in a 6month period. A total of two vials of Zyderm I and half of a vial of Zyderm II were used. Fig. 4 shows the patient prior to the injections, and Fig. 5 was taken 8 months later. Saliva no longer escapes from oral commissures, and angular cheilosis has not reoccurred during 8 months of posttreatment observations. Case 2 A 32-year-ol d man came to the office Complaining of persistent and irritating dermatitis of the left oral commissure for many months. More recently he developed the sam e problem in the riglit oral commissure. Vertical facial dimensions were decreased (A = 72 mm, B = 62 mm). Examination revealed a decrease in the height of the teeth, probably secondary to bruxism. Following the manufacturer's instructions preliminary to the use of Collagen implant, a total of two vials of Zyderrn I have been used in the oral commissures on three occasions over a period of 2 months. The depth of the sulci have been decreased, and during 3 months of posttreatment observation angular cheilosis has not reoccurred.
Fig. S. Patient 1. Photograph was taken 8 months after Fig. 4 and 2 months after completion Of collagen implantation of sulci extending from 0ral commissures.
COMMENT The prescribing of vitamins and the search for allergic contact dermatitis often are not helpful in the management of angular cheilosis. Topical broad-spectrum antimicrobial agents in ointment base (to shield the skin from saliva) are beneficial. However, if saliva continues to escape in soft tissue sulci extending inferolaterally from the corners of the mouth, signs and symptoms will persistently reoccur. If the sulci are secondary to decreased vertical dimension of the lower one third Of the face, some patients can be helped by capping worn or eroded teeth, replacing lost teeth, or increasing the height of dentures to compensate for alveolar bone re-
496
Journal of the American Acad6my of Dermatology
Chernosky
sorption. 4'5 In m a n y patients, however, the dentist m a y choose not to increase this vertical dimension because of other important factors such as improper function of the temporomandibular joint, premature striking o f the teeth, phonetics, and the patient's overall comfort and appearance. A more direct approach to decreasing the depth o f the grooves angling from the comers of the mouth has been undertaken by using injectable collagen implant. In two patients this approach has b e e n successful and angular cheilosis has not recurred. Long-term posttreatment observations are not yet available, but additional injections of collagen implant will probably be required. Injectable collagen implant has been used successfuUy primarily to improve the appearance of scars and facial wrinkles. 6 The treatment of angular cheilosis must b e added to the list of indications for its use.
ADDENDUM The two patients described were followed for an additional 3-month period. There has been no recurrence of perl~che nor need for further treatment.
REFERENCES 1. Chernosky ME: Dental conditions of diagnostic aid in mucocutaneous medicine. Arch Dermatol 84:115-122, 1961 2. Chernosky ME: Relationship between vertical facial dimension and perl~ehe. Arch Dermatol 93:332-337, 1966, 3. Chemosky ME: Dry skin and its consequences. J Am IVied Wom Assoc 27:133-142, 145, 1972. 4. Swenson MG: Complete dentures, St. Louis, 1940, The C. V. Mosby CO., p. 655, 5. Spies TD, Mann AW, Springer FM: Preliminary report on the effect of mechanical increase in the vertical dimension of the face in angular cheilosis. J Dent Res 21:305-306, 1942. 6. Castrow FF, Krull EA: Injectable collagen implant--update. J AM ACADDERMATOL9:889-8932 1983.
ABSTRACTS Skin penetration of benzoyl peroxide (German text) Seubert S, Seubert A, Ippen I-I: Hautarzt 35:455-458, 1984 The benzoyl peroxide content of abraded horny layer and its metabolite benzoic acid were examined by high-pressure liquid chromatography after 1 to 2 minutes application of an emulsion containing benzoyl peroxide. Benzoylperoxide penetrates the horny layer very quickly and is rapidly changed into benzoic acid. A depot of benzoyI peroxide could not be found in the horny layer. No depot formation is necessary for the therapeuticeffect of benzoyl peroxide since within 2 hours after its use a strong bacterial reduction occurs.
Alfred Hollander. M.D.
drawal, relapses occurred after 3 to 18 months, The effective mechanism is yet unknown.
Alfred Hollander, M.D.
Porphyria cutanea tarda and chronic lymphatic leukemia (German text) Montag H, Schmeel A: Z Hautkr 59:1372-1376, 1984 A 58-year-old patient had porphyria cutanea tarda that was diagnosed in August 1983. Enlarged lymph nodes of the axillary and inguinal regions existed for at least 10 years. Other lymph nodes enlarged recently. Histologically, chronic lymphatic leukemia was found. In this case, as in two other similar cases in the literature, it is assumed that the lymphoma triggered the development of porphyria cutanea tarda.
Cheilitis granulomatosa (Melkersson-Rosenthal syndrome): Treatment with clofazimine (German
Alfred Hollander, M.D.
text)
Camouflage therapy
Neuhofer J, Frisch P: Hautarzt 35:459-463, 1984
Downie, M: Australas J Dermatol 25:89-91, 1984
Seven patients with cheilitis granulomatosa, three of them with completeMelkerss0n-Rosenthal syndrome, were treated with the leprostatic agent clofazimine, 100 mg daily for I0 days; thereafter, they were treated with 100 mg 2 to 4 times weekly for 2 to 12 months. The treatment response of the swelling of the lips was generally favorable. Some persistent residual swelling responded only incompletely. The therapeutic influenceon lingua plicata and facial paresis could not be judged from these few observations. After drug with-
Three camouflage cosmetics (Dermacolor, West Germany; Covermark, Lydia O'Leary; and Keromask, Innoxa) were compared in thirty-one patients with a variety of disfiguring lesions. Of eleven vitiligo patients, six preferred Dermacolor and five, Covermark. Of the variety of other lesions, ineluding hemangiomas, scarring, keloids, telangiectasia, ere., Dermacolor was preferred.
J.G.S.