By Gary M. White, MD
The lower lip is red and scaly with whitish areas.
Actinic Cheilitis is inflammation of the lower lip caused by chronic sun exposure.
The typical early changes are scaly, hyperkeratotic areas along the edge of the lip adjacent to the vermilion border. Only limited areas may be involved in mild disease. For extensive damage, the entire lower lip may be involved. A solitary white plaque (leukoplakia) of the lower lip is a common presentation. The edge closest to the oral cavity is usually well-defined whereas the edge closest to the skin fades out gradually (see photo below).
One key characteristic of actinic cheilitis is that just the lower lip is involved in contrast to allergic contact dermatitis where both the upper and lower lip show changes.
The healthcare provider should put on a glove and palpate the lip to exclude any nodularity or induration suggestive of a squamous cell carcinoma (SCC). A complete skin examination to look for skin cancers should also be performed.
All patients must understand the damage the sun's rays are doing to their lips and the potential for the development of squamous cell carcinoma. Patients should begin the daily use of a lip balm with an SPF of at least 15 and avoid excessive time in the sun.
The specific areas of actinic cheilitis usually respond well to cryotherapy. If any area/lesion does not resolve and return to normal, it should be biopsied. Usually a shave biopsy is performed to minimize scarring. The patient should be instructed to protect the lower lip from chronic sun exposure and to return any time the lip is not normal. The lip deserves special surveillance as lip SCCs more frequently metastasize than cutaneous SCCs.
If the involvement is extensive, 5-FU treatment may be considered although the patient must accept several weeks of severe crusting, pain, and erosion. The 5-FU 5% cream or liquid may be given QD-BID for 7-10 days. By the end of this time, the lips are usually quite eroded. The patient may then apply Vaseline (or even be given viscous lidocaine if pain is significant) until healing occurs. If at all possible, patients should be seen during this time for monitoring and reassurance.
Imiquimod cleared actinic cheilitis in an open study of 15 patients [JAAD 2002;47;497]. One approach is to apply the 3.75 or 5% daily till erosion occurs--typically 2-3 weeks (patients can send you a photo every day or two for you to help monitor). Then stop and apply an occlusive ointment till heals. The therapy is not for the faint of heart as the inflammation can be tremendous but is usually very effective with good cosmesis.
Laser resurfacing is highly effective. In one study, electrodessication was equivalent to CO2 laser, except for a longer healing time [Derm Surg 2000;26;349].
Photodynamic therapy (PDT) may be used for mild to moderate cases.
A white plaque of the lower lip (leukoplakia) is a common presentation.
Small keratotic areas may be frozen with close followup. Any lesion that can't be cleared must be biopsied.
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