Exfoliative cheilitis related to psychologic factors uncovered during primary immunodeficiency evaluation

A 40-year-old previously healthy, non-atopic woman was referred for evaluation of a possible immunodeficiency disorder in the setting of an unusual erosive cheilitis and history of recurrent methicillin-resistant Staphylococcus aureus (MRSA) infection. Extensive work-up was non-diagnostic, including screening for immunologic disorders. She had failed multiple therapeutic modalities, including corticosteroid and immunosuppressive therapy. Tissue biopsy from the lip proved pivotal in demonstrating changes suggestive of factitial disease. This led to further detailed history-taking, yielding evidence of considerable psychologic distress. The patient was diagnosed with exfoliative cheilitis related to factitial disease in association with underlying untreated anxiety and psychologic trauma.