A 31-year-old secretary complained of recurrent lip blistering. She had suffered from blisters on the lips since she was a teenager. The blistering affected either one or both lips, and appeared spontaneously or after sun exposure. She was aware of no other precipitants and had no other mucocutaneous, ocular or genital complaints and no fever or allergies. She was on no medication. Her medical history was otherwise clear, apart from hay fever. She was teetotal.
Extra-oral examination revealed no significant abnormalities apart from the lip blistering as shown (Figure 1), and specifically no cervical lymph node enlargement, or cranial nerve, salivary or temporomandibular joint abnormalities or pyrexia. Oral examination revealed no abnormalities whatsoever.
Figure 1. Lip blisters.
Q1. What is the probable cause?
Herpetic infection;
Fixed drug reaction;
Bullous disease;
Burns;
Contact allergic cheilitis.
A1. The answer to what is the probable cause?
Herpetic infection is the likely cause. The frequency, location and clinical characteristics of lip bullae, as well as the age of onset, confirms that our patient suffered from recurrent herpes labialis. Multiple vesicles on the lips and around the mouth are seen in infections by the herpes simplex virus (HSV) type 1 mainly, and mostly in recurrences (herpes labialis or ‘cold sores’). Herpes labialis is characterized by a number of small vesicles with clear fluid on the lips and adjacent skin which either fuse, forming a large bulla, or break, leaving superficial ulcerations with itching rather than pain or other symptoms. The vesicles in primary herpetic stomatitis are usually also scattered on the whole oral mucosa and associated with erythematous swollen gingivae, cervical lymphadenopathy, and sometimes fever and fatigue.
Fixed drug reaction is an adverse drug reaction that results in fluid-filled blisters or bullae on lip, mouth skin and other organs. It can be localized and mild or widespread and severe and associated with erythema, itching, scaling and multiple blisters which break leaving extensive painful ulcerations. It occurs at the same site every time when the patient takes the causative drug, such as aspirin, ibuprofen and other NSAIDs, antibiotics, such as penicillin, azithromycin, sulphonamides, diuretics, gold or penicillamine. Our patient was not on any medication.
Bullous diseases can present with lip blistering, mainly in erythema multiforme and paraneoplastic pemphigus, but blisters may be seen in pemphigoid, pemphigus, linear IgA disease, and epidermolysis bullosa. Although bullous diseases can occasionally present at a similar age to that of our patient, their lesions often appear also in sites other than the lips.
Burns can occur accidentally in normal patients and frequently in patients with mental health issues. Typically, they arise from direct contact of lips with extremely hot foods or drinks (thermal), or corrosive chemicals such as battery liquid; alcohol, phenols, drugs such as aspirin (chemical) and electric current leakage (electrical) can cause accidental burns. Our patient had no history of lip direct contact with these various factors.
Contact allergic cheilitis is caused by lip exposure to allergens, commonly found in cosmetic lipsticks or lip balms, in sun creams, foods, toothpastes and dental materials and usually manifests as a diffuse lip erythematous swelling with itching, burning sensation, scaling and bullae formation and appearing within a few hours after the exposure.
