MINISTRY OF HEALTHCARE OF UKRAINE

Danylo Halytsky Lviv National Medical University

Department of Dermatology, Venereology

METHODICAL INSTRUCTION
for students of the IV course
of faculty of dentistry

Practical class:
CHEILITES

Lviv – 2016
 Methodical instruction has been prepeared by employers of Department
of Dermatology, Venereology of Danylo Halytsky Lviv National Medical
University: Syzon O., Bilynska O., Babak I., Astsaturov H., Chaplyk-Chyzho I.,
Dashko M., Voznyak I.

Methodical instruction has been prepeared based on the Typical

Programs for Students of IV Accreditation Level Higher Medical Educational
Institution Medical and Dental Faculties, such as Skin and Venereal Diseases
(Ministry of Public Health of Ukraine, 2014).

Responsible for issue: dean of the Foreign Students’ Faculty, prof. Y.

Varyvoda

Reviewers: MD, proff. V. Zubachyk

PhD, assist.prof. H. Lishchuk-Yakymovych

Methodical instruction has been recommended for publication by the

Profiled Methodical Committee of the Medical Faculty of Danylo Halytsky Lviv
National Medical University

(Protocol №________ from ___________________ 2016)

 INTERDISCIPLINE INTEGRATION

Subjects To know To be able to

1. Epidemiology Тhe prevalence of Determine the epidemic
cheilites; factors of cheilites;
2. Histology Cell structure; Recognize under the
microscope the nucleus
cytoplasm, the cell
membrane;
3. Structural changes of the Microscopically evaluate
Pathoanatomy skin; histopathological morphologic features of
signs of cheilites; cheilites;
4. Dermatology Clinical manifestation, Carry out inspection, to
evolution of rash, the stages evaluate the results of
of clinical course; instrumental methods.

PLAN AND ORGANIZATIONAL STRUCTURE OF THE LESSON

The main Education Control methods Materials of Duration

№ phases of al aims in of the training methodological
class, their the support
function and assimilatio
content n levels
І. The preparatory phase
1. Organization 4 min.
studies
2. Educational
objectives
3. Test control
input
knowledge:
1. Etiology and І-ІІ Methods of the Clearness 30 min.
pathogenesis of first level
cheilites. 1. Express survey Questions, tables,
2. Test control of models, structural
the first level schemes
2. Clinical ІІ Methods of the
manifestation second level
of cheilites. 1. The individual Questions.
oral examination.
2. Solving of Tasks of the
typical tasks. second level.
3. The written The written
 ІІ-ІІІ theoretical survey. theoretical task.
4. Test control of Tests of the
the second level. second level.
Methods of the
3. Diagnostic ІІІ third level
criteria of 1. Solving of Tasks of the third
cheilites. atypical tasks. level.
4. Treatment of
cheilites. 2. Test control of Tests of the third
5. Prevention the third level. level.
of cheilites.
ІІ. The main stage: 135 min.
ІІІ . The final stage
1. Control and ІІІ Control methods 1.
correction of of skills. Equipment.
professional The individual 2. Situational tasks of the third
knowledge, control of level.
abilities, skills practical skills or 3. Results of patient’s
its results. supervision.
Control methods
of professional
2. Sum up the knowledge
lessons.
а) solving of
3. Homework for atypical situational Algorithms, work with
the next lesson tasks; literature.
б) control of
results of
laboratory
research.

Cheilites (cheilitis) is agroup of diseases in which inflammation is localized only on the lips (on the
red border, mucous membrane), as well as some diseases, whose course is characterized by
predominant lesion of the red border of the lips.
TRAINING AND EDUCATIONAL OBJECTIVES

■ To summarize the modem concept of the etiopathogenesis of cheilites

■ To distinguish routes and possible conditions of the body's
sensitization
■ To identify factors influencing the course of cheilites
■ To summarize characteristics of the clinical course of cheilites
■ To determine general principles of differential diagnosis, treatment and
 prevention of cheilites
■ To identify therapeutic tactics for patients with cheilitis
TO KNOW

- etiopathogenic characteristics of cheilites;

- peculiarities of classification and clinical manifestations of independent (weather,
exfoliative, glandular, contact and actinic) and symptomatic (atopic, of eczematous
cheilitis, plasma cell, macrochilia etc.) cheilites;
- comparative description of independent and symptomatic cheilites;
- principles of treatment and prevention of independent and symptomatic cheilites.

TO BE ABLE TO

- correctly collect past history of patients with cheilitis;

- set a diagnosis based on clinical presentation,
- determine diagnostic tests to confirm the diagnosis,
- perform differential diagnosis of patients with diseases having similar clinical
picture;
- prescribe individual pathogenetic treatment.

The term «cheilitis» denotes not the cause of the disease, characteristics of its
course and morphological changes, but only on the localization of the pathological process.
The red border, the mucous membrane of the lips may be involved in this process in many
dermatoses, characterized in most cases by diffuse inflammation. Lesion of the lips may be
a manifestation of allergic, infectious diseases, cancer, and various other states. There is still no
generally accepted classification of cheilites, and this makes it difficult to diagnose and leads
to prescription of non-rational therapy.

Classification. Cheilites is divided into two groups: independent and

symptomatic.
The group of independent cheilites includes meteorological, exfoliative,
glandular, contact and actinic cheilites.
The group of symptomatic cheilites include atopic, of eczematous cheilitis (lip
eczema), plasma cell, macrocheilitis (Rossolimo-Melkersson-Rosenthal's
syndrome), cheilitis on the background of ichthyosis and caused by vitamin
deficiency.

Meteorological cheilitis

Meteorological or simple cheilitis (cheilitis meteorological) is an

inflammatory disease of the mouth caused by physical effects of various
meteorological factors on the red border.

Etiopathogenesis. The factors that cause development of meteorological

cheilitis may be moisture, dryness, wind, heat, cold, dust. Often the disease develops in people
who work outdoors, especially in adverse weather conditions.

Clinical picture. In meteorological cheilitis, the red border of the lips is affected, usually
the lower one, along its entire length. The lip becomes slightly erythematous, dry, often covered
with small scales, patients suffer from dry or tight sensation, many lick their lips, which leads
to increased dryness, peeling, and then the red border infiltration. When scales are
removed, painful erosion is exposed and may bleed. The skin and mucous lips are
unchanged.

Diagnosis. The diagnosis is set based on past history and physical

examination. Laboratory tests are not advisable.

Differential diagnosis. It is necessary to differentiate meteorological cheilitis

with allergic, actinic, atopic with cheilitis and dry form of exfoliative cheilitis.

Treatment. To treat meteorological cheilitis, it is necessary to exclude or

diminish the impact of meteorological factors. Recommendation: topical barrier
creams, vitamin therapy (B„ B6, Bp, PP, C).
Prognosis is favorable.

Exfoliative cheilitis

Exfoliative cheilitis (cheilitis exfoliativa), synonym: Mikulicz-KbmmeVs

disease is a chronic disease that affects only the vermilion border. The skin and
mucous membrane are never involved in the pathological process.
 Etiopathogenesis is not fully studied. The disease can be caused by neurogenic
mechanisms and thyroid dysfunction.

Clinical picture. There are two forms of the disease: dry and exudative, both are
different phases of the same disease and can easily be transformed into each other.
The exudative form of exfoliative cheilitis is characterized by appearance of
grayish-yellow scales, crusts on the red border of the lips, which cover the red border with a
layer from comer to comer of the mouth, beginning from the transition zone of the oral
mucosa, Klein s line, till the middle of the vermilion border. Sometimes the crust is rather
large and hangs from the lips like an apron. The disease is accompanied by severe burning and
soreness, especially when the lips are closed, when eating and talking. Such patients almost
always keep their mouth half open.
The dry form of exfoliative cheilitis, just as exudative, characterized by
localized lesions only on the red border of one or both lips. The lesion is in the form of a
ribbon extending from the mouth corner to corner and from Klein's line to the
middle of the red border of the lips. Commissure of the mouth remains free from
lesions. Part of the red border belonging to the skin always remains unaffected. Gray or
grayish brown flakes are tightly attached to the red border in the center and a little behind on
the edges. Patient suffers from burning and dryness. After 5-7 days flakes easily exfoliate,
exposing bare shiny red surface with no erosion.
Diagnosis. Diagnosis of exfoliative cheilitis is divided into:
- linical (based on past history and physical examination);
- laboratory (thyroid function tests);
- instrumental (histopathological study if necessary, if acanthosis,
parakeratosis, hyperkeratosis is observed).
Differential diagnosis. The exudative form must be differentiated from
exudative form of actinic cheilitis, pemphigus vulgaris, erosive and ulcerative
form of lupus, other types of Cheilites.
Treatment. Treatment of patients with exfoliative cheilitis is a difficult task and
implies correction of concomitant neurological and endocrine pathology. Local therapy should
include sanation of the oral cavity, use of keratoplasty means (oil solution of vitamin A and
E, kartolin). Local corticosteroids are used in the exudative form.
Prognosis is favorable. Subject to correction of endocrine and
psychopathological disorders, quite stable remission is achieved.
Glandular cheilitis
Glandular cheilitis (cheilitis glandularis) is a disease that develops as a result of
hyperplasia, hyperthyroidism, and often heterotypic form of the salivary glands in the
vermilion border and the transition zone.
Etiopathogenesis. The cause of glandular cheilitis can be a congenital anomaly in which
a large number of small salivary mucous glands are located in the transition zone (Klein's zone)
and red border, or the glacis may have normal location, and their ducts are moved to the
surface of the red border. Under the influence of stimulation the glands become
hypertrophied and produce discharge intensively.
Clinical picture. There are primary and secondary glandular cheilitis.
Primary glandular cheilitis is manifested mainly after puberty. In the area of the
mucous membrane transition in the vermillion border of the lips, and sometimes on the red
border there are prominent dilated entries of salivary glands in the form of red dots,
excreting droplets of saliva. 5-10 seconds after the lips are dried, salivation from entries of the
salivary glands become clearly visible, and saliva covers the lip like dew drops.
Development of secondary glandular cheilitis is obviously due to the fact that the
inflammatory infiltrate, characteristic of the underlying disease, irritates the salivary glands,
causing their hyperplasia and hyperactivity. In this case, against the background of
the main manifestations of the disease, more frequently on lip mucosa in the transition zone
area there are enlarged entries of salivary glands excreting droplets of saliva.
Frequent wetting of the red border with saliva in glandular cheilitis contributes to
dryness, maceration and leads to chronic fissures. Later on, the mucosa and the red border
may gradually coarsen.
Diagnosis. Diagnosis of the disease based on past history and physical
examination is not difficult.
Differential diagnosis. Differential diagnosis of glandular cheilitis is easy due to
clear clinical signs and presence of enlarged ducts of glands.
 Treatment Anti-inflammatory corticosteroid ointments, punctate electrocoagulation
ofhypertrophied glands or cryodestruction are used to treat glandular cheilitis.
If a patient with glandular cheilitis has a great number of abnormal glands, their
surgical excision is performed. In secondary glandular cheilitis it is necessary to treat the
underlying disease.
Prognosis is favorable. At superficial electrocoagulation or cryodestruction
clogging of ducts of salivary glands and formation of cysts may be observed.
Contact allergic cheilitis
Contact allergic cheilitis (cheilitis alergica contactis) is a disease, developing due
to sensitization of the vermilion border or, less frequently - mucosa, to chemicals and occurs
when lip mucosa direct contacts the allergen.
Etiopathogenesis. Contact allergic cheilitis is a clinical manifestation of delayed- type
hypersensitivity. Most often it is a reaction to chemicals used in lipstick, toothpaste
and other cosmetic products, in particular fluorescent substances and eosin,
rhodamine, etc. This disease mostly affects women.
Clinical picture. In clinical terms, contact allergic cheilitis is manifested through severe
burning and itching. Usually the process is localized on the red border of the lips, sometimes
it extends slightly to the skin of the lips. At the point of contact with the allergen there occurs a
rather well-defined erythema and slight peeling. In long-term course of the disease the red
border of the lips become dry and has small transverse grooves and cracks.
Diagnosis. Contact allergic cheilitis is diagnosed based on clinical examination
findings and, where appropriate, allergy tests.
Differential diagnosis. This disease is differentiated with dry forms of exfoliative
cheilitis, actinic and atopic cheilitis.
Treatment. In treatment of allergic contact cheilitis first of all it is necessary to
eliminate a causative factor of the disease. If the clinical picture of the disease is mildly expressed,
it is possible to prescribe only local treatment- corticosteroid ointments to be applied 5-6 times
a day. In more severe cases, desensitizing therapy should be used.
Prognosis is favorable subject to maximum elimination of the allergen.
Actinic cheilitis
 Actinic cheilitis (cheilitis actinica) is a chronic disease caused by
hypersensitivity of the red border of the lips to sunlight.
Etiopathogenesis. the main causes of this cheilitis are delayed reaction to
ultraviolet rays, i.e. actinic cheilitis develops in people with sensitization of the red border of
the lips to solar radiation. The dry form of actinic cheilitis is considered to be elective precancer.
Classification. There are exudative and xeronous (dry) forms of actinic cheilitis.
Clinical picture. The exudative form of actinic cheilitis is often found in
individuals with hypersensitivity to sun exposure, so the clinical picture is consistent with
evidence of acute allergic contact dermatitis.
In spring the red border of the lower lip in the xeronous (dry) form of actinic
cheilitis turns bright red, covered with small dry silvery-white scales. The lesion covers
the entire surface of the red border. A number of patients develop keratinization areas
on the red border; sometimes verrucous mass occur.
Diagnosis. Actinic cheilitis is diagnosed on the basis of medical history and
physical examination. If necessary, a smear mark to exclude cellular atypia, and
dermal biopsy is recommended.
Differential diagnosis. There is actinic cheilitis with dry forms of exfoliative
cheilitis, atopic and meteorological cheilitis. A characteristic diagnostic feature is the process
exacerbation under the influence of insolation.
Treatment. First of all, it is necessary to recommend that the patient avoids sun
exposure and changes an occupation, if it is associated with prolonged stay in the open air.
Hyposensitization drugs, nicotinic acid are prescribed. Topical steroids are used locally
inactinic cheilitis.
Prognosis is favorable, however in long-term keratosis is necessary to exclude
malignancy.
Symptomatic cheilites
Symptomatic cheilites is a group of cheilites, which are one of the main clinical
manifestations of the underlying disease. There are atopic cheilitis, eczematous
cheilitis, plasma cell cheilitis, Miescher's granulomatous macrocheilitis, Meiji's
rophoderm, and Rossolimo-Melkersson-Rosenthal's syndrome.
 Atopic cheilitis (cheilitis atopica) is one of the symptoms of atopic dermatitis,
which is often the only manifestation of this disease at its certain stages.
Etiopathogenesis. Atopic cheilitis is a genetically caused disease accompanied by
disorders of the central and autonomic nervous system. It is more common in girls and boys
aged 4 to 17 years old.
Clinical picture. In clinical terms, atopic cheilitis affects the red border of the lips and
always the skin, and the process is more intensive in the corner of the mouth. The part of the red
border, adjacent to the oral mucosa and the oral mucosa remain unaffected. The
disease manifests itself through itching, erythema and lip lichenification.
Diagnosis and differential diagnosis. In exfoliative cheilitis, unlike atopic, a part
of the vermilion border is always affected in the form of a strip from the Klein's line to the
middle of the red border; a part of the vermilion border adjacent to the skin is intact; the process
never affects the skin of the lips and does not cover the corners of the mouth; there is no
erythema and lip lichenification; the course of the disease characterized by monotony and lack
of remission. Past history of patients with actinic cheilitis shows a clear dependence of
exacerbations on insolation; there is no frank lesion of the mouth comers characteristic of atopic
cheilitis. In allergic contact cheilitis lichenification is only observed during prolonged course of
the disease; there are no sores at the corners of the mouth; the course depends on direct
contact with the allergen. In some cases, differential diagnosis of atopic cheilitis with
symmetrical streptococcal or Candida bridoes can be quite difficult. In bridoes, localization of
the lesion is limited only to the mouth comers; as a rule, lichenification is not observed.
Treatment. Treatment includes prescription of antihistamines and sedatives,
vitamins.
Eczematous cheilitis (cheilitis eczematosa). All types of eczematous cheilitis are
grouped together according to similarity of clinical manifestations, but they occur for different
reasons. There are eczematous cheilites: caused by seborrheic eczema; microbial
eczematous cheilitis; contact eczematous cheilitis.
Cheilitis in seborrheic eczema. Cheilitis is one of the symptoms of seborrheic
eczema, but only the lips may be affected. In clinical terms, it manifests through
hyperemia of the red border of the lips, occurrence of easily separated flakes,
bubbles. Skin of the lips and the red border is dry, cracks and flakes appear.
Microbial eczematous cheilitis cheilitis. Re-develops against seborrheic
eczema due pyococcal infection (mainly streptococcal) at the site of formation.
Clinical manifestations correspond to microbial eczema.
Contact eczematous cheilitis cheilitis. Develops due to an allergic reaction to a
variety of chemicals (in the lipstick, toothpaste, etc.). The clinical picture is consistent with acute
or chronic eczema and is quite varied: swelling of the lips, bright hyperemia, blisters with
subsequent formation of crusts. Elimination of allergen leads to rapid resolution of
cheilitis.
Treatment In eczematous cheilitis treatment is similar to that of eczema. Topical
steroids and antibiotics are used.
Macrocheilitis
Macrocheilitis (macrocheiliti). This is the name for Rossolimo-Melkersson-
Rosenthal's syndrome Meiji's trophoderm, Miescher's granulomatous macrocheilitis,
characterized by persistent lip swelling. At this time it is known that granulomatous
Miescher's cheilitis is not an independent nosological form of the disease and is a variant of
Rossolimo-Melkersson-Rosenthal's syndrome with development of granulomatous infiltrate in
the affected tissue. Meiji's trophoderm refers to angiotrophoneurosis. Rossolimo-
Melkersson-Rosenthal's syndrome combines a triad of symptoms: macrocheilia
(persistent increase in the lip), neuritis of the facial nerve, folded tongue, and a chronic disease
with a tendency to recur. The disease occurs both in men and in women at any age, but most
often between 16 and 35 years old.
Etiopathogenesis. The causes of Rossolimo-Melkersson-Rosenthal's
syndrome are not fully clear. Neurological manifestations of Rossolimo-Melkersson-
Rosenthal's syndrome often may include neuritis or facial nerve paresis and paralysis of the
facial muscles.
Clinical picture. The onset of the disease is sudden. During few hours the lips get
swollen. Swelling lasts 3-6 days, seldom less, sometimes longer, even up to a month. At the
same time there is swelling of the mucous membranes of the oral cavity. Examination
reveals deformation of the lips, the increase in their volume. The lip is dense at palpation.
The mucous membrane of the mouth may be edematous, its surface becomes uneven,
with a white cushion along the line of the teeth compression. There develops quite clear
coarsening of the mucosa, various degrees of folding and lobulation of the tongue.
The course of Rossolimo-Melkersson-Rosenthal's syndrome is chronic. At the
onset of the disease relapses are usually replaced by more or less prolonged
remissions, during which all symptoms of the disease resolve. Later, macrocheilia and paralysis
of the facial nerve become stable.
Diagnosis. Some patients with Rossolimo-Melkersson-Rosenthal's syndrome
may lack both the folding of the tongue and paralysis of the facial nerve. The only
symptom of the disease in this case is macrocheilitis.
The impairment of the facial nerve manifests through the face distortion to the
healthy side, smoothing of the nasolabial fold. There are signs of the cranial nerve
impairment (trigeminal, auditory, etc.). Along with a thorough dental
examination of the patient, identification of odontogenic, tonsillogenic and other
sites of infection it is necessary to determine sensitivity to bacterial allergens with
leukolysis reaction, as well as the neurological status.
Differential diagnosis. It is performed with angioedema, lymphangioma,
hemangioma, collateral edema of the lips in periostitis of the upper or lower jaw.
Treatment. Treatment of Rossolimo-Melkersson-Rosenthal's syndrome is
performed in two directions: surgical and conservative. In surgical treatment, which is
performed for cosmetic purposes, a part of lip tissue is excised. However, surgical
treatment does not prevent recurrences of the disease. Conservative treatment
includes corticosteroids, broad-spectrum antibiotics and synthetic anti-malarial
drugs.
EDUCATING TASKS AND CONTROL
I level

1. What is the predominant localization of lesions in cheilites:

A. Corners of the mouth
B. Lip mucosa
C. Klein's zone only
D. All surface of the red border of the lips
E. All of the above
2. The group of independent cheilites comprises:
A. Meteorological
B. Exfoliative
C. Glandular
D. Actinic
E. All of the above
3. There are the following types of symptomatic cheilites:
A. Atopic cheilitis
B. Macrocheilitis
C. Meiji's trophoderm
D. Rossolimo-Melkersson-Rosenthal's syndrome
E. All of the above
4. Exfoliative cheilitis has two forms:
A. Dry and exudative
B. Seborrheal and genuine
C. Verrucous and intertrigo
D. Vegetative and pustular
E. None of the above
5. The following is observed in the serous form of glandular cheilitis:
A. Bloody dew symptom
B. Dew symptom
C. Apple jelly symptom
D. Stearic spot symptom
E. Probe symptom
6. Actinic cheilitis is a chronic disease caused by.
A. Hyperplasia, hyperactivity and often heterotypia of salivary glands around
the red border of the lips
B. Effect of various meteorological factors on the red border of the lips
C. Solar hypersensitivity the red border of the lips
D. Sensitization of the red border of the lips to chemicals
E. Clinical manifestations of the underlying disease
7. There are the following types of eczematous cheilitis:
A. Caused by seborrheic eczema
B. Caused by microbial eczema
C. Contact eczematous cheilitis
D. None of the above
E. All of the above
8. Rossolimo-Melkersson-Rosenthal's syndrome unites a
triad of symptom:
A. Macrocheilia, face angioneurosis, hoarse voice
B. Macrocheilia, sinusitis, vestibulitis
C. Macrocheilia, mitral insufficiency, optic neuritis
D. Macrocheilia, facial nerve neuritis, folded tongue
E. None of the above
9. Differential diagnosis of Rossolimo- M e l k e r s s o n - R o s e n t h a l ' s
syndrome is performed with:
A. Quincke's edema
B. Lymphangioma
C. Hemangioma
D. Collateral edema of lips in periostitis of the upper or lower jaw
E. All of the above
II – III levels

Task 1. A 46 year-old patient complains of dryness, itching, peeling of the red

border of the lips. The disease occurs in cold windy weather.
a) Set a provisional diagnosis:
A. Atopic cheilitis
B. Meteorological cheilitis
C. Glandular cheilitis
D. Actinic cheilitis
E. Exfoliative cheilitis
b) Specify preventive measures and prognosis.

Task 2. A 34-year-old woman contacted a dermatologist complaining of oral

mucosa lesions. According to past history, symptoms in the form oferythema of
the red border, minor swelling, peeling, itching repeatedly occurred in this patient
after using certain types of lipsticks.
a) Which is the most probable diagnosis:
A. Contact allergic dermatitis
B. Common contact dermatitis
C. genuine lip eczema
D. Contact allergic cheilitis
E. Actinic cheilitis
b) Determine a treatment tactics.

Task 3. A 32-year-old woman contacted a dermatologist complaining of

spontaneous increase of the red border, painful sensations in that area.
Objectively: lip swelling and congestive hyperemia. Clearly visualized enlarged
ducts of the salivary glands excreting transparent viscous secret in the form of
droplets (dew symptom). Around the ducts entries there is inflammatory
infiltration.
a) Which disease can be assumed:
A. Urticaria fever
B. Contact allergic cheilitis
C. Serous glandular cheilitis
D. Common contact dermatitis
E. Purulent glandular cheilitis
b) Perform differential diagnosis of this disease.

Task 4. A16-year-old contacted a dermatologist complaining of rash on the lip

mucosa,
surrounding skin and sensation of dryness and tightness in these areas. Clinically:
the red border of the lips and the surrounding skin are hyperemic, with cracks and
easily detaching scales on the surface.
a) What is the possible provisional diagnosis:
A. Cheilitis caused by seborrheic eczema
B. Cheilitis caused by microbial eczema
 C. Contact eczematous cheilitis cheilitis
D. Rossolimo-Melkersson-Rosenthal's syndrome
E. None of the above
b) Specify therapeutic and preventive recommendations.

Task 5. A woman contacted a dermatologist complaining of deformation of the

upper lip, increase in its volume and itching. According to past history, the
disease onset was sudden. The upper lip got swollen within a few hours.
Objectively: there is amorphous swelling of the upper lip, its edge is twisted in the
form of a proboscis and it detached from the teeth. The upper lip is bluish, dense
at palpation. Swelling of the oral mucous membranes is observed.
a) Set a provisional diagnosis:
A. Atopic cheilitis
B. Macrocheilitis
C. Purulent glandular cheilitis
D. Rossolimo-Melkersson-Rosenthal's syndrome
E. Urticaria fever

1) b) What is the necessary pre-hospitalization assistance?

Answers to the questions of the first level of complexity
1 - E; 2 - E; 3 - E; 4 - A, 5 - B; 6 - C; 7- E; 8 - D; 9 - E
Answers to the questions of the second and third levels of complexity
1a-B;2a-D;3a-C;4a-A,5a-B
References:
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Kozin. – M.: Med.lit., 2013. – 672p.
2. Stepanenko V.I. Dermatology. Venereology. Textbook // V.I.
Stepanenko, M.M. Shupenko, O.O. Syzon [et al.] - Kyiv.: KIM, 2013. – 560
p., 257 pic.
3. Skin and venereal diseases. Textbook / V.H.Kolyadenko, V.I.
Stepanenko, P.V.Fedorych, S.I.Sklyar. – К.: Nova knyha, 2006. – 424p.
4. Skin and venereal diseases/ under the edithorship of Prof., Y.К.
Skripkin. – Moscow: Medicina, 1995. – V. 3. – 447 p.
5. Romanenko I.М. et al. The treatment of skin and venereal diseases. –
М., 2006. – 884p.