What is your approach to diagnosis and treatment to intermittent cheilitis that does not respond to anti fungal therapy?

Clinical features matter. The differential is broad: granulomatous cheilitis, contact dermatitis, irritant dermatitis, lichen planus, and I have even seen SCLE present with cheilitis. Biopsy during a flare can be helpful even if only to rule out some possibilities, and a 3mm punch typically heals quite well. Check if patient drinks from a metal straw or water bottle which can cause contact in nickel allergic patients, and many lip balms can cause significant cheilitis. A reasonable first step is to only ever use Vaseline and avoid all other topicals for 6 weeks. Address behaviors (lip biting, licking). A low potency steroid like desonide ointment or a tacrolimus ointment for a short period can be helpful. Sometimes oral fluconazole is more ...