Actinic Cheilosis (Cheilitis)
Quick Summary Introduction References Photos		Clinical Features Histopathology Treatment Prognosis
Smooth lower lip vermilion has large leukoplakia lesion with small midline chronic ulcer.

Quick Review for Patients

Introduction

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Actinic cheilosis (actinic cheilitis) is a diffuse, degenerative, irreversible alteration of the vermilion border of the lips which results from excessive exposure to ultraviolet light. It primarily affects persons with light complexions, especially those with a tendency to sunburn easily.

Clinical Features

Actinic cheilosis is a disease of persons older than 50 years of age and its frequency increases with advancing age thereafter. The male:female ratio is as high as 10:1 in some studies. Almost all cases occur on the lower lip vermilion, probably because of the more direct sunlight exposure of that site.

The labial changes develop so slowly that the patient is frequently unaware of a change, beginning with mild puffiness and vermilion atrophy with admixed blotchy areas of pallor and erythema, perhaps with a bluish background hue (Figures 1 & 2). The normal demarcation between the vermilion zone and the skin of the lip becomes blurred or disappears (Figure 3). As the lesion progresses, rough, scaly areas develop on the drier portions of the vermilion, appearing is some cases as leukoplakia (Figure 4). Painless ulceration may develop in one or more sites, especially in areas of mild trauma. Ulcers may last for months, even years, and may be difficult to differentiate from ulcerated squamous cell carcinoma, although the latter is typically more indurated. Ulcers more than two months old should be biopsied in order to evaluate for malignancy.

Pathology and Differential Diagnosis

 Atrophic stratified squamous epithelium is seen, often with marked parakeratin production and possibly with epithelial dysplasia of the basal and parabasal layers. Rete ridges may be lost. The subepithelial stroma invariably demonstrates an amorphous, acellular, lightly basophilic change (solar elastosis, actinic elastosis) from the ultraviolet light-induced breakdown of collagen fibers (Figures 5-7). Fibrovascular tissues above and below the elastosis are often scattered with lymphocytes. The lower margin of the elastosis is relatively uniform throughout the lip, but areas of involvement may be separated laterally by less damaged stroma.

Treatment and Prognosis

Actinic cheilosis is an irreversible change and squamous cell carcinoma, almost always well-differentiated, develops in 6-10% of cases. Malignant transformation seldom occurs prior to 60 years of age and the resulting carcinoma typically enlarges so slowly and metastasizes so late that one population study found no deaths and minimal morbidity from the carcinomas.

Follow-up is recommended and patients should use lip balm with sunscreens in order to prevent further degeneration. Occurrence of induration, thickening, ulceration, or leukoplakia should lead to biopsy for histopathologic evaluation. In severe cases without malignancy, a lip shave procedure (vermilionectomy) can remove the vermilion mucosa and replace it with a portion of the intraoral labial mucosa.

References (Chronologic Order)

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General references:

Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. Philadelphia, W. B. Saunders; 1995.

Elder D, Elenitsas R, Jaworsky C, Johnson B Jr. Lever's Histopathology of the skin, 8th edition. Philadelphia; Lippincott-Raven, 1997.

Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. Mosby; St. Louis, 1997.

Odell EW, Morgan PR. Biopsy pathology of the oral tissues. London; Chapman & hall Medical, 1998.

Specific references:

Wright K, et al. Actinic cheilitis. Dermatol Surg 1998; 24:490-491.

Pictures

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