It’s winter. Chances are that if you live anywhere cold and dry, your lips have been chapped at least once this season. For most of us, we slather on the lip balm and all is well. But for some folks, the chapped lip experience is an entirely different animal: A relentless cycle of peeling and healing, peeling and healing that no amount of lip balm resolves. Lips are fissured and inflamed, making speaking, eating or smiling painful endeavors. Individuals with chronic chapped lips (cheilitis simplex or the more severe exfoliative cheilitis) become self-conscious of their appearance. Such was the case with Mary, a bright 24 year old woman (and naturopathic medical student!) who first came to see me this past Fall.
While Mary mentioned her lips at our first meeting, her main complaint was small intestinal bacterial overgrowth (SIBO). She had a positive hydrogen/methane breath test ordered by another physician, but hadn’t yet resolved the symptoms of gas, bloating and severe abdominal pain. This was clearly our first goal.
Mary had these same gut issues dating back to her teen years, which coincided with the start of her cheilitis.
We addressed her gut with a combination of a FODMAP diet, botanicals (my current favorite protocol includes enteric-coated peppermint oil and berberine) and betaine-HCL with meals. Mary avoided all probiotics which can worsen SIBO symptoms. We identified nutrient needs, including zinc (which I prescribed as zinc carnosine- great for healing an inflamed gut) magnesium, vitamins A and E and CoQ10. Mary was already taking a B complex with a good amount of B12, riboflavin, methylated folate and methylcobalamin.
While she probably didn’t need more B’s, I decided to increase them short term on the off-chance they helped with her lips. Angular cheilitis-sores along the corners of the mouth-is known to be associated with a riboflavin deficiency but can also be seen with folate, niacin, B12, B6 or zinc deficiencies. And all of these nutrients could be low in SIBO, caused by bacterial-induced hypochlorhydria and maldigestion.
As Mary began to feel better on the SIBO protocol, she contacted me rather urgently via email, reminding me of her painful lips. She included a photo. Her lips were worse than ever, she said. Peeling, healing, peeling, healing. It didn’t look good. We were clearly unsuccessful with the high-dose B trial. And all the lip potions in the world made no difference.
I’ll admit her chapped lips were a head scratcher for me. Especially given how chronic and totally unresponsive to treatment they were! She wasn’t a lip licker or biter. She was well-hydrated. Her diet was good, and her nutrient needs were met. She does tend a bit towards anxiety, but it just didn’t strike me as a fundamental player in her chapped lips, as it can be for some, because she had good tools for addressing her stress.
A clue was the temporal association with the onset of both SIBO and chapped lips. Could there be some microbial overgrowth also perpetuating the cheilitis? Dr. Alex Vasquez calls this “multifocal dysbiosis” that is, microbial imbalances occurring at different areas in the body, driven by systemic issues. I’ll admit: it seemed long shot, but a shot nonetheless. A look in the literature identified that both candida albicans and various bacteria have been associated with exfoliative cheilitis, but most often in immunocompromised folks. Since she is a patient who lives out of state, I didn’t take a swab for culture. But fortunately for us, functional medicine is generally quite safe, and a trial with a botanical antimicrobial concoction wouldn’t hurt.
I decided to go with a combination of coconut oil and berberine-about 1 TBS of coconut oil mixed with 500mg berberine, applied liberally and often. Easy. She wanted to add probiotics to the mixture. It seemed a reasonable idea to me.
A couple week later, Mary emailed me with glee- her lips were so much better! She needed to apply the combination often, but it really seemed to be helping. All of these ingredients could be useful on their own, I suppose. And those coconut oil acolytes out there I am sure will suspect it’s the key. But together, the combination worked and continues to work. See her follow up photo below.
Incidentally, Mary’s case made me think of another. I treated a patient with trigeminal neuralgia when I worked at a tertiary care pain clinic some years ago. Facial pain was so severe in this woman that she maintained an unsupervised liquid diet for years. It was simply too painful for her to chew. She presented with classic angular cheilitis and not surprisingly, it cleared immediately when she started a good, high dose B complex. Multiple B deficiencies- induced by a poor diet- were the key to resolving her issue.
Further reading.
Wikipedia has a pretty nice short page on the various types and causes of cheilitis. DermNet also has a good section. The last link is a case report using a 10% calendula ointment for chelitis.
http://en.wikipedia.org/wiki/Cheilitis#Exfoliative_cheilitis
http://www.dermnetnz.org/site-age-specific/exfoliative-cheilitis.html
http://www.casesjournal.com/content/2/1/9077