D2.62 - Atypical Chronic Cheilitis as Manifestation of Atopic Dermatitis: A Diagnostic Dilemma

Background: Chronic cheilitis is a frequent manifestation of atopic dermatitis (AD), typically presenting as eczematous inflammation with erythema and scaling. Rarely, AD-related cheilitis may present as persistent, localized, non-pitting labial edema with a granulomatous-like clinical appearance. Concomitant findings such as fissured tongue – another under-recognized feature in atopic patients – may further complicate clinical interpretation. This presentation can closely mimic granulomatous cheilitis of Miescher, resulting in a significant diagnostic challenge. We report an atypical, treatment-refractory form of atopic cheilitis characterized by persistent lip tumefaction and associated fissured tongue, highlighting an under-recognized clinical phenotype.

Case Presentation: A 19-year-old male with an atopic background presented with persistent, non-pruritic, non-pitting edema of the central upper lip and a fissured tongue. The onset occurred in June 2025 following significant emotional stress, initially manifesting as exfoliative cheilitis and later progressing to stable labial tumefaction. 

Treatment with high-potency topical corticosteroid (clobetasol propionate) produced no improvement; a subsequent trial of topical tacrolimus (0.1%) led to only a partial response. Physical examination revealed minor features of atopic dermatitis, including xerosis, keratosis pilaris, nummular eczema on the forearm, and retro-auricular hyperlinearity; nevertheless, no major diagnostic criteria for AD were present. Laboratory investigations showed an elevated total IgE level, consistent with the patient’s atopic profile. 

Extensive investigations were undertaken to exclude allergic contact dermatitis and systemic disease. Patch testing (European Baseline Series) was negative, and serological evaluation, including serum iron, vitamin B12, ANA, anti-dsDNA antibodies, and infectious screening, was unremarkable. 

Given the persistent lip edema and fissured tongue, granulomatous cheilitis was strongly suspected, and a biopsy was performed. Histopathology demonstrated a non-specific chronic inflammatory infiltrate without non-caseating granulomas, supporting an eczematous process. The final diagnosis was an atypical, granulomatous-like (“pseudogranulomatous”) presentation of atopic cheilitis.

Conclusion: AD may present with cheilitis phenotypes beyond classic eczematous changes. Chronic inflammation can lead to persistent localized lip edema mimicking Miescher’s cheilitis, and fissured tongue may coexist with atopy and be overlooked. Histopathology is essential to exclude granulomatous cheilitis and other rare inflammatory disorders, thereby directing management toward appropriate atopic disease control.