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Table of Contents 
Year : 2016  |  Volume : 61  |  Issue : 1  |  Page : 123
Recurrent bleeding lip in an adolescent female - Chasing the cause

1 Department of Dermatology and STD, Vinayaka Mission's Medical College and Hospital, Karaikal, Pondicherry, India
2 Department of Psychiatry, Vinayaka Mission's Medical College and Hospital, Karaikal, Pondicherry, India

Date of Web Publication15-Jan-2016

Correspondence Address:
Arunprasath Palanisamy
Department of Dermatology and STD, Vinayaka Mission's Medical College and Hospital, Karaikal, Pondicherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5154.174142

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How to cite this article:
Palanisamy A, Subramani N, Reji S, Kothandapany S. Recurrent bleeding lip in an adolescent female - Chasing the cause. Indian J Dermatol 2016;61:123

How to cite this URL:
Palanisamy A, Subramani N, Reji S, Kothandapany S. Recurrent bleeding lip in an adolescent female - Chasing the cause. Indian J Dermatol [serial online] 2016 [cited 2023 Mar 24];61:123. Available from:


A 15-year-old adolescent girl presented with complaints of recurrent episodes of fissuring, bleeding, and crusting of the lower lip for 7 months. There was no history of photosensitivity, drug intake, or any topical application over the lips. She denied habits such as lip licking, picking of scales, and lip biting. Examination revealed multiple fissures and hemorrhagic crusts involving the lower lip [Figure 1]. Palpation of the lip did not reveal any nodular lesions. A diagnosis of actinic cheilitis was considered and was prescribed zinc cream and emollients. However, 1 week later, she presented with much pronounced hemorrhagic crusting [Figure 2]. After a brief period of occlusion of the lip with liquid paraffin soaked gauze, the crusts were removed, leaving a bitten off appearance [Figure 3]. Examination of hair and mucous membranes were normal. Systemic examination did not reveal any abnormality.
Figure 1: Fissures and mild crusting involving the lower lip

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Figure 2: Striking hemorrhagic crusting giving a "stuck on" appearance

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Figure 3: Removed crusts and bitten off appearance of lower lip

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Routine hematological and biochemical investigations were within normal limits. Histopathological examination of the punch biopsy specimen revealed features suggestive of chronic inflammation [Figure 4]. There was no granuloma, dysplasia or mucous glandular distension. A diagnosis of factitious cheilitis (FC) was suspected, and psychiatry opinion was sought.
Figure 4: Hyperkeratosis, acanthosis and inflammatory dermal infiltrate (H and E, ×10)

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In the psychiatric evaluation, she revealed that her parents were overprotective and giving more care and attention to her younger sister only. She encountered frequent relationship issues with her parents and sibling, which led to a frequent flare-up of lesions ranging from minor fissuring and erosion to frank bleeding and crusting; however, she consistently denied self-infliction. Despite her past proficient scholastic performance, she had dropped out from school for 7 months citing her illness. The psychological assessment revealed borderline personality traits, impulsivity, poor frustration tolerance, and above average intelligence scores.

A diagnosis of FC was entertained and managed with supportive psychotherapy, parental counseling, and manipulation of environment like rejoining of school. Fluoxetine was prescribed to reduce impulsivity alongside topical emollient and occlusion of the lip to prevent lip biting activity. In due course, the lesions regressed [Figure 5].
Figure 5: Regressed lesions with impression of chronic lip biting

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FC has been described as dryness, scaling, and fissuring of the lips resulting from mannerisms like biting or frequent licking. FC should be considered in patients presenting with unusual hemorrhagic crusting of the lips in the absence of an appreciable cause and when deliberate manipulation of the lips is suspected. [1] The crusting in FC could be very thick, formed from layers of hemorrhagic exudates giving the appearance of coagulated blood or serum over the lips. [2] In this present case, initially, there was minimal serous and hemorrhagic crusting, however, later presented with striking hemorrhagic crusting giving a "stuck on" appearance.

The psychogenic cause for FC was proposed by Brocq in 1921. [3] In factitious dermatitis, patients deliberately self-inflict lesions on themselves to fulfill their unconscious motive to seek attention and emotional care from their family. [4] Schaffer et al. pointed out an underlying borderline personality disorder and a precipitating psychosocial stressor in such patients. [5] Borderline personality disorder is characterized by emotional instability, unstable interpersonal relationships, poor self-identity, and frequent deliberate self-harm. [4] In this case, the intention of the patient is to divert her parents attention toward her, competing with her sister.

Having a hunch regarding the chances of intentional self-harm is important because these patients refuse their involvement in the production of lesions. [6] Multiple diagnostic tests are often nonspecific. Diagnosis is generally confirmed by demonstrating the skin lesions to resolve under occlusion, [6] so was the scenario in the present case.

The differential diagnoses of crusted lip lesions include candida cheilitis, actinic cheilitis, exfoliative cheilitis, cheilitis glandularis, granulomatous cheilitis, contact dermatitis, and photosensitivity. [1] The terms exfoliative cheilitis and FC are used synonymously at times. Aydin et al. alluded that exfoliative cheilitis is a disorder in which lesion are produced impulsively or compulsively without any attention seeking behavior, unlike FC and emphasized on distinguishing these two conditions, which bears significance in the context of treatment. [3]

Treatment should be centered on supportive and empathetic approach. There is no standard treatment for the factitious disorder, other than targeting treatable comorbid psychiatric disorders. The presence of mood or anxiety bodes for a better prognosis, whereas an underlying personality disorder for a poorer prognosis. [7] Occlusive dressings and emollients will help in reducing the destructive self-inflicting acts on the skin. FC is an uncommon presentation among the factitious dermatoses. A high index of suspicion and awareness about the condition might aid in early diagnosis and appropriate management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Crotty CP, Dicken CH. Factitious lip crusting. Arch Dermatol 1981;117:338-40.  Back to cited text no. 1
Millard LG, Millard J. Psychocutaneous disorders. In: Burns T, Breathnach S, Cox NH, Griffiths C, editors. Rook's Textbook of Dermatology. 8 th ed. Oxford: Wiley Blackwell; 2010. p. 64.35-64.39.  Back to cited text no. 2
Aydin E, Gokoglu O, Ozcurumez G, Aydin H. Factitious cheilitis: A case report. J Med Case Rep 2008;2:29.  Back to cited text no. 3
Ghosh S, Behere RV, Sharma P, Sreejayan K. Psychiatric evaluation in dermatology: An overview. Indian J Dermatol 2013;58:39-43.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
Schaffer CB, Carroll J, Abramowitz SI. Self-mutilation and the borderline personality. J Nerv Ment Dis 1982;170:468-73.  Back to cited text no. 5
Calobrisi SD, Baselga E, Miller ES, Esterly NB. Factitial cheilitis in an adolescent. Pediatr Dermatol 1999;16:12-5.  Back to cited text no. 6
Wang DL, Powsner S, Eisendrath SJ. Factitious disorder. In: Sadock BJ, Sadock WA, Ruiz P, editors. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 9 th ed. Philadelphia: Lippincott, Williams and Wilkins; 2009. p. 1949-64.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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