Actinic cheilitis

Actinic cheilitis also known as “farmer’s lip” or “sailor’s lip”, is a precancerous skin condition related to cumulative lifetime sun exposure. Cheilitis refers to an inflammatory process of the lips that has many causes. The lower lip is most often affected. Individuals with actinic cheilitis often complain of persistent dryness and cracking of the lips. They will frequently exhibit other effects of sun-damaged skin, such as precancerous lesions on the skin called actinic keratoses and extensive wrinkling. Actinic cheilitis is also called actinic cheilosis, solar cheilitis, and sometimes, actinic cheilitis with histological atypia. Actinic cheilitis also describes lip involvement in actinic prurigo, a rare form of photosensitivity.

Actinic cheilitis presents as diffuse or patchy dryness and variable thickening of the vermilion of the lower lip. The common form of actinic cheilitis is due to chronic sun exposure and is the lip form of actinic keratosis.

Actinic cheilitis is significantly more common in men, the elderly, and fair-skinned individuals. There is also a strong association with tobacco use. The best prevention for actinic cheilitis is the use of sunscreen and the avoidance of sun exposure ¹. In smokers, the risk of cancer can be reduced by smoking cessation.

In a review the medical literature with data collected from scientific journals in the last 30 years ², the mean age of the patients was 56 years old; 42 patients (56%) were female, and 66 patients (88%) were white. Nineteen (25.3%) patients reported at least one symptom, including pain, burning and itching. Sixty-five (86.7%) patients presented actinic cheilitis only in the lower lip. All of the patients reported sun exposure, and 44 (58.6%) patients were exposed for more than 10 years. The main clinical aspects investigated and analyzed included dryness (100%), flaking (72%) and white lesions (57.3%).

A certain type of skin cancer (squamous cell carcinoma) develops in 20% of cases of actinic cheilitis ².

In severe cases without evidence of malignancy, a lip shave procedure (vermilionectomy) may be performed. In less extreme cases, your physician may recommend destruction (ablation) of the damaged cells with a carbon dioxide (CO2) laser.

Alternative treatments include the use of electric current to destroy the precancerous cells (electrodesiccation) and a facial sanding technique (dermabrasion). Topical therapy with a chemotherapeutic agent (fluorouracil) or a topical immunomodulator (imiquimod) may be prescribed.

Figure 1. Actinic cheilitis

Footnote: Actinic cheilitis clinical characteristics. (A) Brown stain and diffuse blurring between the border of the lip and the skin; (B) Ulcer and white lesion; (C) Dryness and flaking; (D) Diffuse blurring between the border of the lip and the skin.

Actinic cheilitis causes

Actinic cheilitis results from chronic exposure of the lower lip to solar ultraviolet radiation. It is more vulnerable than surrounding skin because mucosal epithelium is thinner and less pigmented than the epidermis.

Actinic cheilitis mainly affects adults with fair skin who live in tropical or subtropical areas, especially outdoor workers. They often recall having sunburned lips in earlier years. They may also have actinic keratoses on other sun-exposed sites of the scalp, ears, face and hands.

Actinic cheilitis is three times more common in males than in females.

Actinic cheilitis prevention

Actinic cheilitis prevention is very important. Wearing barrier clothing (eg, wide-brimmed hats) and sunscreen-containing lip balms can aid in preventing actinic cheilitis. In smokers, the risk of cancer can be reduced by smoking cessation.

Actinic cheilitis symptoms

Actinic cheilitis is located on the lips, most often the lower lip. Persistent redness, scaliness, and chapping are among the symptoms noted. Erosions and cracks (fissures) may be present as well.

Actinic cheilitis most commonly affects the lower lip (90%), and causes:

• Dryness
• Thinned, fragile, skin
• Thickened, scaly papules and plaques (actinic keratoses)

Less common features of actinic cheilitis include:

• Swelling
• Redness
• Soreness
• Fissuring, focal ulceration and crusting
• Loss of demarcation between the vermilion border of the lip and its adjacent skin
• White thickened patches (leukokeratosis)
• Discoloured skin with pale or yellow areas
• Prominent folds and lip lines
• Difficulty applying lipstick, which tends to “bleed” into the surrounding lines

Actinic cheilitis possible complications

Actinic cheilitis is a pre-malignant condition. It predisposes to:

• Intraepidermal carcinoma (Bowen disease or squamous cell carcinoma in situ)
• Invasive squamous cell carcinoma

Cancer of the lip is more common in smokers than in non-smokers. Other factors include oncogenic human papillomavirus (wart virus), alcohol abuse and immunosuppression.

Invasive squamous cell carcinoma should be suspected if the lip is focally tender, or a persistent ulcer or enlarging nodule develops.

Actinic cheilitis diagnosis

Actinic cheilitis is usually diagnosed clinically. A skin biopsy may be taken if skin cancer or an inflammatory cause of cheilitis is suspected.

The pathological features of actinic cheilitis are variable thickening or atrophy of the lip, partial thickness epidermal dysplasia, solar elastosis and inflammation in the dermis.

To establish the histopathological diagnosis of actinic cheilitis, some morphological parameters must be considered, including acanthosis, thicker keratin layer (parakeratosis or orthokeratosis), solar elastosis (the most consistent histological finding), the presence of inflammatory infiltration and perivascular inflammation ². However, other common findings may be encountered, such as dyskeratosis, hyperplasia and hypotrophy. The histological aspects vary according to the grade of epithelial dysplasia, especially with respect to the presence of hyperchromic enlarged cellular nuclei with irregular shapes and occasional atypical mitosis ¹.

Actinic cheilitis treatment

Smoking cessation and lifelong, year-round, daily sun protection are essential.

• Limit sun exposure
• Wear a hat with a wide brim
• Apply sunscreen-containing lip balm frequently

Men can consider growing a moustache.

Topical therapies for actinic cheilitis are unapproved. They include:

• Topical retinoids
• 5-fluorouracil cream
• Imiquimod cream
• Photodynamic therapy

Physical treatments for actinic cheilitis include:

• Cryotherapy
• Electrocautery
• Vermilionectomy (surgical removal of the external lip)
• Laser ablation, eg with Erbium YAG laser.

Because actinic cheilitis may develop into squamous cell carcinoma and subsequently metastasise, patients must undergo a thorough investigation and long-term follow-up. These patients require aggressive treatment, according to the clinical evolution and histologic features ³. Histopathological results will determine the type of approach, and treatment modalities are numerous, each with its own advantages and disadvantages ³. One of the most common treatments is vermilionectomy, and other modalities include CO2 or erbium lasers, electrodessication, topical
application of 5-fluorouracil tretinoin, topical imiquimod, trichloroacetic acid chemical peel, photodynamic therapy using 5-aminolevulinic acid (5-ALA) and thulium laser ⁴. After concluding treatment, the patient must undergo rigorous follow-up and periodic exams with clinical control consultations because remaining lesions may change their appearance ⁵.

Actinic cheilitis prognosis

Actinic cheilitis can improve with effective sun protection and treatment. Continued sun exposure and lack of treatment increase the risk of squamous cell carcinoma, which is potentially life threatening.

Many studies have been conducted with the purpose of identifying prognostic markers that identify lesions with a greater potential for malignant transformation. However, a predictive prognostic marker for these malignant transformations in actinic cheilitis has yet to be identified. Research has been focused thus far on the evaluation of the immunohistochemical expression of the p53 protein ⁶. Other immunohistochemical markers have also been used, including Bax, Bcl-2, the cell proliferation marker Ki-67 ⁷, MDM2 ⁸, p21 ⁹, p63 proteins ¹⁰, hMLH1 and hMSH2 ¹¹. Fibroblast and mast cell densities have also been studied, suggesting that these cells may contribute to the tumor progression in its invasion front ¹².

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