Cheilitis granulomatosa (Miescher)

Synonyms: Miescher

By Dr. Pascal Bafteh · last updated 09/2026

Overview

• Cheilitis granulomatosa Miescher: chronic-recurrent, painless swelling of the lips (often upper lip), histologically non-caseating granulomas. Common in young men.
• Melkersson-Rosenthal Syndrome: The classic triad is granulomatous cheilitis + lingua plicata (fissured tongue) + facial palsy. Complete triad is rare — also mono- / oligosymptomatic course possible (mostly isolated granulomatous cheilitis Miescher); swelling can also occur on the tongue or palate.

• Further options (off label): fumaric acid esters have been used successfully in granulomatous cheilitis and Melkersson-Rosenthal syndrome in case reports and small series and are regarded as a steroid-sparing option; further options are clofazimine, doxycycline/minocycline, dapsone, hydroxychloroquine and TNF blockers (infliximab, adalimumab). For refractory, disfiguring macrocheilia, cheiloplasty under continued anti-inflammatory therapy is possible.

Diagnosis — a diagnosis of exclusion

• Principle: granulomatous cheilitis and Melkersson-Rosenthal syndrome are diagnoses of exclusion: the non-caseating granulomas are non-specific and occur equally in sarcoidosis, Crohn's disease and foreign-body reactions.
• Biopsy: deep lip biopsy showing non-caseating epithelioid cell granulomas, lymphoedema and a perivascular lymphocytic infiltrate; in early stages granulomas may still be absent (only oedema and infiltrate) — repeat biopsy is justified.
• To be excluded:
• Sarcoidosis: chest X-ray or CT (bihilar lymphadenopathy), sACE, serum and urinary calcium, soluble IL-2 receptor, ophthalmological examination.
• Crohn's disease / orofacial granulomatosis: gastroenterological work-up (faecal calprotectin, endoscopy if indicated) — orofacial granulomatosis may precede intestinal disease by years, especially in children and adolescents.
• Infections: tuberculosis (IGRA), atypical mycobacteriosis, deep mycoses.
• Contact allergy / foreign body: patch testing including the dental material series (amalgam/mercury, gold, nickel, palladium) as well as flavourings and preservatives (cinnamaldehyde, benzoates); contact allergy can perpetuate granulomatous cheilitis — plus dental restoration.
• With facial palsy: exclude other causes (neuroborreliosis, zoster oticus, space-occupying lesion) by serology and, if needed, MRI.

Differential diagnoses

• Angioedema
• Fissured tongue (lingua plicata)
• Erysipelas
• Cutaneous sarcoidosis
• Allergic contact dermatitis

Sources (selection)

1. AWMF S3 AK 2023

More inflammatory skin diseases

• Erythema annulare centrifugum (EAC)
• Erythema nodosum
• Graft-versus-host disease (GvHD)
• Granuloma annulare
• Cutaneous sarcoidosis
• Lichen planus
• Lichen sclerosus
• Lichenoid drug eruption

Note: This page is intended for medical education and does not replace diagnosis or treatment decisions in individual cases. Treatment and follow-up content is available in the app.