Actinic Cheilitis

Premalignant condition of the lip vermilion caused by chronic ultraviolet exposure, equivalent to actinic keratosis of the lip. Over 90% occur on the lower lip, which receives the most sun.

• Typical patient: fair skinned (Fitzpatrick I and II) man over 45 years who works outdoors (farming, fishing, construction, sport). Other factors are smoking (including pipe smoking), immunosuppression (organ transplant recipients have a far higher risk), chronic lip trauma and a history of skin cancer.
• Histology shows epidermal atrophy or hyperplasia with keratinocyte dysplasia and solar elastosis in the dermis.
• Progression to squamous cell carcinoma occurs in roughly 10 to 20% over years, with reported figures ranging widely. Lip squamous cell carcinoma metastasises to regional nodes in about 5 to 15%, and metastatic disease reduces 5-year survival from above 90% to about 50%.

• Early: dryness, scaling, mild erythema and roughness of the lower lip, with a sandpaper feel.
• Established: pale, atrophic, mottled white and red areas, loss of the sharp line between the vermilion and the skin, fissures, small erosions and recurrent crusting. Symptoms are often mild or absent.
• Red flags for malignant change: a persistent ulcer or erosion over 3 weeks, induration or thickening on palpation, a hard nodule, bleeding, a verrucous or thick white plaque, numbness of the chin or lip, and enlarged submental, submandibular or cervical nodes.
• Differential diagnosis: chronic cheilitis (contact, lip lick, exfoliative), herpes labialis, lichen planus, discoid lupus erythematosus, leukoplakia, candidiasis, cheilitis glandularis, keratoacanthoma and squamous cell carcinoma.
• Complications: transformation to squamous cell carcinoma, nodal and perineural spread, and scarring from treatment.

• Clinical examination of the whole lip under good light, with stretching of the lip, and palpation for induration. Examine and palpate the neck, and record the sun exposure history and smoking.
• Dermoscopy or clinical photographs are used for monitoring.
• Biopsy (3 to 4 mm punch or incisional wedge) from the most suspicious area before treatment, and from any lesion that is ulcerated, indurated, thick, white, or persistent. Take more than one specimen from extensive disease, since dysplasia varies across the lip.
• Ultrasound of the neck, and if invasive disease is confirmed, MRI or CT for lip depth and nodal assessment.
• In transplant recipients and other immunosuppressed patients, examine the skin generally and lower the threshold for biopsy.

• Prevention and risk reduction for everyone:
  • Broad spectrum SPF 30 or more lip balm, applied every 2 hours outdoors, and after eating and swimming.
  • Wide brimmed hat, shade and avoidance of peak sun hours.
  • Stop smoking and reduce alcohol.
  • Treat chronic cheilitis and lip trauma.
• Field treatment (topical), for diffuse disease with no suspicion of invasion:
  • Fluorouracil 5% cream twice daily for 2 to 4 weeks. Expect marked redness, erosion, crusting and pain in weeks 2 to 3, which settles within 2 to 4 weeks after stopping. Clearance is about 50 to 90%, with recurrence over time. Avoid in pregnancy. Check for known dihydropyrimidine dehydrogenase deficiency before extensive treatment.
  • Imiquimod 5% cream at night 3 times weekly for 4 to 8 weeks (off label for the lip). Local reaction is expected, and flu like symptoms are possible.
  • Diclofenac 3% gel in hyaluronic acid twice daily for 60 to 90 days, gentler but slower (evidence is limited).
• Photodynamic therapy: methyl aminolevulinate 160 mg/g cream applied under occlusion for 3 hours, followed by red light (about 37 J/cm2, 630 to 635 nm), repeated after 1 week. It gives good cosmetic results and clearance of about 70 to 90%, with significant pain during illumination.
• Destructive treatment for localised lesions:
  • Cryotherapy with liquid nitrogen spray, 2 freeze thaw cycles of 10 to 20 seconds each, with blistering and healing over 1 to 3 weeks.
  • Carbon dioxide or erbium:YAG laser ablation, with good cosmetic results but a risk of scarring and a lack of tissue for histology (biopsy first).
  • Electrodessication and curettage for small areas.
• Surgical treatment for extensive, recurrent, thick, or suspicious disease: vermilionectomy (lip shave), removing the affected vermilion with a mucosal advancement flap. Recurrence is about 5 to 10%, and cosmetic and functional results are usually good. Send the whole specimen for histology.
• If squamous cell carcinoma is confirmed:
  • Wedge resection with 4 to 6 mm margins for tumours up to one third of the lip, with primary closure, or Mohs micrographic surgery for tissue sparing.
  • Larger tumours need reconstruction (lip switch, commissure and rotation advancement flaps, or other regional flaps).
  • Radiotherapy is used for patients unfit for surgery and as adjuvant treatment for perineural invasion or positive margins.
  • Neck dissection or sentinel node biopsy for nodal disease, or for high risk tumours (more than 4 mm thick, poor differentiation, perineural invasion, recurrent).
  • Refer urgently to head and neck, or plastic and reconstructive surgery.
• Chemoprevention in transplant recipients with multiple lesions: acitretin 10 to 25 mg orally daily, under specialist care (contraindicated in pregnancy and for 3 years after stopping in women of childbearing potential, with monitoring of lipids and liver tests).
• Special groups:
  • Pregnancy: sun protection and cryotherapy for small lesions. Defer fluorouracil and imiquimod until after delivery.
  • Elderly: choose the least invasive effective option, since many are frail.
  • Immunosuppression: treat early, follow closely every 3 to 6 months, and use a low threshold for biopsy.
• Follow up: review at 4 to 6 weeks after topical or destructive treatment, then every 6 to 12 months for life. Re-biopsy any lesion that persists or recurs.