Exfoliative cheilitis is an uncommon and chronic inflammatory disorder affecting the vermilion of the lips and characterized by continuous peeling of the vermilion and abnormal production of keratin scales12. Conventional topical treatment is helpful in some cases but it is not that effective in most cases. Invasive treatment such as peeling with laser, cryosurgery and electrocautery is effective in some cases but it can cause severe discomfort1.

A 42-year-old male presented with 4 years of history of chronic thick yellowish hyperkeratotic plaques on both lips. The plaques became thicker and were accompanied by pain and oozing (Fig. 1A). He denied lip licking, biting or rubbing habits. The lesion was resistant to conventional topical treatment such as salicylic acid 10% ointment and vaseline. He complained that his lips kept getting crusts in spite of conventional treatments. In pathologic examination, it showed nonspecific chronic inflammation with interface dermatitis and lymphoplasmacytic infiltration in the upper dermis (Fig. 2). Based on histopathologic findings, we added the process to diagnosis. Although relatively larger numbers of plasma cells are usually present in the mucosal biopsies and may be non-specific, we checked serum antibodies because secondary syphilis can show lymphoplasmacytic infiltration and interface change with lichenoid infiltration. The results of serology test such as venereal disease research laboratory (VDRL) was negative. Therefore, considering the nonspecific chronic inflammation on pathology and clinical features, the patient was diagnosed as chronic exfoliative cheilitis. We treated him with pinhole method using CO₂ laser after removing the thick plaques which removed easily by gauze rubbing. We made multiple single spot-sized holes at intervals of 1 mm by using CO₂ laser with super-pulse mode, continuous wave and 0.5 to 1 watt. The lesion was almost improved without side effect such as severe pain, discomfort and scar. Almost all of the thick yellowish hyperkeratotic plaques disappeared and he did not feel pain and oozing (Fig. 1B). After three treatment sessions with intervals of 3 months, the lesions remained clear without recurrence for a year. One year later, mild hyperkeratotic scales and Fordyce spots were observed and additional treatment was performed twice with interval of 1 year. There has been no recurrence for 6 months after last treatment. As the treatment session passed, the treatment interval became longer and the symptoms of the patient become milder.

In exfoliative cheilitis, chronic excessive production and subsequent desquamation of a thick keratin scales occur and the patient experiences some degree of discomfort and pain and difficulty in talking, smiling, and eating2. There are some treatment options such as conventional topical treatment (keratolytic lip balms, sunscreen, antifungal creams and topical steroids), systemic treatment (antidepressants, antifungal agents, and corticosteroids) and invasive treatment (laser, cryosurgery and electrocautery)1. Conventional treatment is helpful in only some cases and invasive treatment usually cause severe pain and discomforts, scarring and delayed wound healing1.

Pinhole method using CO₂ laser can be used to treat burn scar, anetoderma, syringoma, telangiectasia and etc.345. In mechanism, thermal stimulation to the surrounding tissues is known to induce neocollagensis and remodeling of the dermal matrix. Also, laser-induced realignment and regeneration of dermal tissues as well as fibrous tissues surround target lesion can improve the skin texture with reduced downtime and adverse events34. The level of transforming growth factor (TGF)-β1 in the fractional CO₂ laser-treated areas of skin was significantly increased and TGF-β is known to be a potent spur for neocollagenesis and an immunosuppressive cytokine which promotes anti-inflammation. It is presumed that the pinhole method using CO₂ laser will be effective in a similar mechanism in chronic exfoliative cheilitis.

In our patient, pinhole method using CO₂ laser showed more effective with minimal side effects than conventional treatment. The patient felt minimal pain and discomfort after treatment and showed rapid wound healing without scarring. Also, treatment effects lasted longer. In conclusion, pinhole method using CO₂ laser is an effective treatment option for patients with treatment-resistant and chronic exfoliative cheilitis.