Actinic Cheilitis Diagnosis and Treatment

Actinic cheilitis (AC) is a common disease characterized by grayish-white areas of discoloration on the lower lip. It should be effectively diagnosed and treated carefully as it may undergo cancerous transformation.

Diagnosis of Actinic Cheilitis

The diagnosis of AC is based on the clinical and histopathological appearance of the lips, which is complemented by the following tests:

• Patch test: AC due to an allergic reaction is diagnosed through the patch test. The patch test and its readings are implemented in consonance with the standard NACDG (North American Contact Dermatitis Group) training. According to NACDG, a patch which is precoated with 65 allergens (allergy-causing materials) is made to come in contact with the lips. Among the 65 allergens, the patient’s lip will be hypersensitive to at least one patch allergen, which through serial interpretation is recorded as the cause of allergic AC.
• Biopsy test: The diagnosis of AC requires the biopsy test. It involves the removal of a small area of infected lip tissue for the examination of
• either the presence or absence of AC
• If present, the condition of the AC lesion, whether acute, chronic, or carcinomatous
• AC-associated systemic conditions such as lichen planus, atopic dermatitis, lupus, and nutritional deficiencies
• Videoroscopy: It is a diagnostic tool used to select the biopsy area for AC diagnosis, on the basis of examination of images of the lower lip under magnification and sufficient lighting. It is also employed for the follow-up of treated patients because it saves the AC images at each visit, which helps to compare the effectiveness of treatment and the changes at different stages of treatment.
• Reflectance confocal microscopy (RCM): It is a nonintrusive imaging tool that has been recently used in the diagnosis of AC. It is employed for obtaining baseline findings, following up a biopsy test, and to measure tissue damage and treatment efficacy after certain treatments for AC. A recent study used RCM for AC diagnosis and reported that 80% of AC was correctly determined and 100% accuracy obtained in the identification of benign lesions.

Treatment for Actinic Cheilitis

Many treatments are available to achieve a complete cure of AC lesions and for the management of the precancerous stage of AC. All of them require the patient to undergo clinical and histopathological evaluation after several weeks of therapy in order to assess the efficacy of the treatment. Regular follow-up after the completion of treatment is also essential.

Primary Treatment Methods

Cryotherapy

This therapy utilizes extreme cold temperatures to treat the lesion. Cryotherapy specializes in treating localized cancers, which include the carcinogenic stage of AC. The duration of exposure of the affected area to the colder temperature depends on the level of damage sought to be induced. Some side effects may occur, including numbness and redness of lips.

Vermilionectomy (lip shave)

This is a surgical procedure for precancerous lesions of the lips, involving the excision of the lip layer under proper anesthesia. In the cancerous stage of AC, this treatment is often performed with subsequent reconstructive procedures to ensure a positive aesthetic outcome.

Laser therapy

This therapy employs a particular wavelength of light that interacts with the lip tissue to treat AC. Carbon dioxide and Erbium: Yttrium-aluminum garnet (Er:YAG) lasers are commonly used in this treatment, and their individual use has been found to be more effective in this treatment. The cosmetic results are excellent over the short term, with only a low risk of chronic scarring following Er:YAG laser treatment.

Alternative Treatments

These treatments are offered to patients who refuse or are unfit for surgical procedures.

Photodynamic therapy (PDT)

This therapy employs photosensitizing drugs such as methylaminoixypentanoate, flurouracil, or imiquinol, to make the abnormal cells of the lesion susceptible to light-induced damage. These drugs are effective only in the presence of a specific wavelength of light, which differs from one to another. Anesthesia is administered for the control of local pain during the treatment. Sometimes, natural daylight is the active agent when certain photosensitive drugs are used, such as methylaminolevulonic acid.

1. Methylaminoxypentanoate: Researchers used this drug along with red light for the treatment of AC. In most cases, two sessions are conducted with a one-week interval between them. Complete cure and partial cure occurred in 47% of patients each in one study.
2. Methyl-aminolevulonic acid: PDT with this drug is effective in the treatment of AC as it significantly reduces the extent and severity of the lesions. This drug is topically applied in the affected area which is then exposed to red light with a wavelength of 634 mm after 3 hrs. However, many lesions continue to persist after the treatment.

Topical pharmacotherapy

1. Imiquimod and Flurouracil: Both these drugs are antineoplastic drugs. They are effective in treating the carcinogenic stage of AC. These drugs are applied on the lips in cream formulation, the application being continued for up to 6 weeks to produce the optimal effect. Imiquimod has been found to be helpful in managing dysplastic lip lesions and is used after PDT for efficient results.
2. External application of diclofenac in hyaluronic acid gel on the affected lower lip results in the better tolerability of AC.

References

• https://www.ncbi.nlm.nih.gov/pubmed/26681528
• https://www.ncbi.nlm.nih.gov/pubmed/16188193
• https://www.ncbi.nlm.nih.gov/pubmed/26179312
• https://www.ncbi.nlm.nih.gov/pubmed/21916880
• https://www.ncbi.nlm.nih.gov/pubmed/22052302
• https://www.ncbi.nlm.nih.gov/pubmed/3431329
• https://www.ncbi.nlm.nih.gov/pubmed/20846565
• https://www.ncbi.nlm.nih.gov/pubmed/25545762
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464916/?tool=pmcentrez
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4995717/
• https://www.ncbi.nlm.nih.gov/pubmed/20626536

Further Reading

• All Actinic Cheilitis Content
• Actinic Cheilitis Prevention
• Actinic Cheilitis – Symptoms and Causes
• Actinic Cheilitis (AC)
• Actinic Cheilitis Prognosis and Mouth Cancer

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.