Actinic Cheilitis Early Actinic cheilitis, also known as actinic cheilosis, solar cheilitis, solar cheilosis, farmer’s lip, or sailor’s lip, is a precancerous skin condition that arises due to prolonged exposure to the sun (and ultraviolet radiation). Actinic- means arising from solar exposure, and chelitis- means inflammation of the lips. Long-term exposure of the lips to the sun’s radiation induces changes in the structure of the skin layers, which can eventually lead to cancers like squamous cell carcinoma (SCC). Studies estimate that the malignant transformation rate of actinic cheilitis ranges from approximately 6% to 30%, although most lip squamous cell carcinomas arise from pre-existing actinic cheilitis.
The premalignant disorder is characterized by the formation of rough, sharp, and scaly patches on the lips, which usually lack pigment. It mostly affects the lower lip. The disease is more commonly seen in men (aged 60-70 years) and people with fair skin. Due to its high prevalence in outdoor workers like sailors and farmers, the disease is sometimes named accordingly. Quick, accurate diagnosis and timely treatment are important to prevent its conversion to cancer.
Actinic Cheilitis Symptoms: Actinic Cheilitis Early
The lip disease can impact one or both lips. Most frequent issues include having chapped and cracked lips all the time. Individuals with lip inflammation report dryness, irritation, burning, fissuring, and itching.
The lesions, mostly present on the lower lip, become discolored patches that are scaly and swollen. In some cases, the actinic cheilitis lesions are razor-sharp. The persistent white plaques give a “sandpapery” feel on the lips. In the majority of cases, the actinic cheilitis is painless. However, patients experience symptoms like burning, soreness, numbness, and tenderness.
Actinic Cheilitis Stages
Clinically, actinic cheilitis is often categorized into progressive grades based on the severity of changes, although there is no universally standardized staging system.
Grade Ⅰ: Dryness And Flaking
In the first stage, the disease presents with lip dryness and flaking. Patients notice redness alongwith a dry patch on the lip. Studies show that the most common clinical characteristics of the disease are dryness (in 100% cases) and flaking (in 72% cases).
Grade Ⅱ: Vermilion Atrophy
In the second stage, significant changes accompany lip inflammation. There is atrophy (reduction in size) of the vermilion lip. The vermilion lip/zone is the reddish part that is the transition zone between lips and skin. Several patients notice that this region turns pale and thin. Many women have difficulty applying lipstick because the lip line is no longer defined and red. Blurred demarcation between the skin and the lip vermilion border is a commonly noted presentation of the disorder.
Grade Ⅲ: Scaly Patches
This stage is characterized by the formation of rough and scaly patches on the vermilion zone. Most of the time, there is a development of hyperkeratotic regions (thickened outer layer of skin). Histological studies found that hyperkeratosis is the most common feature in samples of actinic cheilitis. Clinicians notice firmness in the lesions on palpation.
Grade Ⅳ: Erosion
In the most advanced stage, there is erosion and formation of ulcers on multiple locations of the vermilion lip. This is at times accompanied by the formation of white patches (leukoplakia), especially in the traumatic areas. These features are observed in cigarette smokers.
How Actinic Cheilitis Turns Into Cancer?
Numerous histopathological changes take place in the lip lesions that can eventually lead to cancer. Early signs are dryness and scaling. Then, there is the development of white (leukoplakia) and reddish patches (erythroplakia). Next is the stage of mild-to-moderate dysplasia, which is characterized by disordered maturation of the keratin-producing cells (keratinocytes).
After this, the connective tissue below your epithelium (outer layer of skin) undergoes damage in a step called solar elastosis. Collagen fibers of irregular thickness accumulate. This is followed by dysplasia (abnormal development/growth of cells) with increased thickness of the keratin layer, i.e., hyperkeratosis.
The dry, crusted lesions of actinic cheilitis have a tendency to turn into carcinoma.
Progression is not always linear, and not all lesions advance to invasive cancer. However, untreated severe dysplasia may evolve into squamous cell carcinoma in situ (also known as Bowen’s disease when occurring on skin) and, in some cases, progress further.
As the disorder advances, carcinoma in situ (CIS) may develop, in which dysplastic cells have not yet invaded deeper underlying tissues. Patients may notice intensely crusted and ulcerated lesions on the lips.
The final stage is invasive squamous cell carcinoma (SCC) in which the malignant keratinocytes invade the neighboring connective tissues. At this stage, patients experience non-healing ulcers or hardened growths. There is a significant risk of metastasis (spread of cancer).
Warning Signs That You Should Be Aware Of
Certain signs indicate a potential conversion of the precancerous condition into a malignancy. Therefore, report to a doctor if you notice these signs:
- There is a persistent ulcer/sore that lasts for more than 2-4 weeks.
- There is an induration on the lip that feels thickened or hard.
- You feel persistent burning or numbness in an oral lesion.
- There is rapid growth of a lesion that may be accompanied by bleeding.
Actinic Cheilitis Causes
The lip disorder is the result of genetic damage induced by exposure to ultraviolet light. Of all the parts of the body, your lips are one of the most vulnerable to the sun’s rays. This is because the skin on the lips is thinner and contains less pigment. Skin pigment acts as a protective barrier against the damaging solar rays. Due to less natural protection on the lip, ultraviolet radiation (UVR) can cause actinic cheilitis and cancer.
UVA penetrates deeper into the skin, whereas UVB is primarily responsible for direct DNA damage and plays a major role in carcinogenesis. Therefore, it is a greater contributor to skin disorders. Chronic exposure induces repeated damage to the skin cells (especially keratinocytes). Normally, the body is capable of repairing damage, but when the damage exceeds the body’s healing potential, an accumulation of damaged/mutated cells occurs, and disease ensues.
Risk Groups
The following people are at a higher risk of developing chelitis:
Cigarette Smokers:
Smoking cigarettes is recognized as a risk factor for actinic cheilitis. Continuous exposure of the lip to cigarette heat enhances the effects of solar radiation, thereby increasing the probability of malignant changes.
Alcoholism:
Another bad habit linked to the precancerous lip condition is alcoholism. In a study on fishermen suffering from actinic cheilitis, 20.5% cases reported frequent alcohol consumption. Therefore, it is concluded that there is a link between alcohol consumption and sailors’ lips.
Fair-Skinned People:
Fitzpatrick skin types Ⅰ and Ⅱ are the lightest skin types that have a high risk of skin disorders, including cancer. The pale, light skin of such individuals is susceptible to sunburns, actinic cheilosis, and actinic keratosis.
Aged People:
Senile individuals above the age of 65 are likely to have been more exposed to the sun than youngsters. Therefore, they are at a greater risk.
Outdoor Workers:
Men involved in outdoor occupations are at greatest risk of the disease because of increased, prolonged exposure to the sun (and UV). Common professions include fishermen, farmers, sailors, construction workers, and lifeguards, etc.
Poor Oral Hygiene:
As the lesions involve your oral region, mouth hygiene is believed to play a part in the occurrence of the disease. Poor oral hygiene is not considered a primary cause but may act as a contributing local factor in some patients.
Individuals Living Near The Equator:
Countries lying close to the equator are more exposed to the sun. Therefore, residents of these nations have a greater chance of developing actinic pathologies. People living at higher altitudes are also at a higher risk.
Immunosuppressed Individuals
Organ transplant recipients and individuals with immunosuppression have a significantly higher risk of actinic cheilitis and its progression to squamous cell carcinoma.
Albinos:
Albinism is a disease characterized by abnormally light pigmentation of the skin. This makes them prone to actinic damage and skin cancers. According to a study, actinic cheilitis was present in 93% of albino patients over the age of 10.
Actinic Cheilitis Diagnosis
Healthcare providers take a history of your symptoms before physically examining the lesions on your lip. Due to the variety of pathologies (both benign and cancerous) on the lip, doctors observe the lesions very carefully. Your doctor will ask you questions about your exposure to the sun and lifestyle habits. Your healthcare provider will carry out a skin biopsy, i.e., remove a part of your skin and send it to a lab for microscopic analysis. A skin biopsy is the gold standard and helps differentiate between non-cancerous (cheilitis), precancerous conditions (actinic cheilitis), and cancerous conditions (SCC).
Differential Diagnosis
Solar cheilitis is similar to many pathologies of the lip. Therefore, it is important to know the difference between these similar maladies.
Actinic Cheilitis Vs Angular Cheilitis:
In the actinic type, we see rough/scaly lesions on the lower lip, while in angular cheilitis, cracked and painful lesions are seen on the corners of the mouth. Moreover, actinic cheilitis lesions are not painful.
Actinic Cheilitis (AC) Vs Basal Cell Carcinoma (BCC):
BCCis a cancerous condition, while solar cheilitis is a precancerous condition. While BCC can affect different regions (scalp, facial skin, etc.), solar cheilosis develops preferably on the lower lip. Dry patches on the lips are seen in AC, but pearly bumps are observed in BCC lesions.
Actinic Chelitis Vs Squamous Cell Carcinoma (SCC):
In most cases, AC converts intoSCC, and it is hard to differentiate between them. However, actinic cheilosis presents with dry scaling of the lip and loss of the border between the skin and the lip. On the other hand, a malignant SCC lesion presents as a persistent, indurated or ulcerated (refractory to conventional treatment) lesion that may bleed.
Actinic Cheilitis Treatment
Timely treatment is crucial as the sun-induced damage can quickly turn into cancer. Healthcare providers use different types of strategies to limit the lesion growth and halt its conversion into a malignant condition. The most frequently adopted strategies include:
Topical Therapy
Early therapy involves applying topical creams containing any of the following compounds:
- 5-Fluorouracil
- Imiquimod
- Trichloroacetic acid
- Ingenol mebutate
Topical preparations containing 5% imiquimod and fluorouracil seem to work well when combined with photodynamic therapy. Moreover, 35% trichloroacetic acid peel is a safe and effective treatment for sailor’s lip. Topical diclofenac gel is also used in some cases.
Minimally Invasive Therapies
Multiple non-interventional treatment modalities can improve symptoms and halt the growth of actinic cheilosis.
Laser Therapy:
Medical lasers work by vaporizing (ablating) the damaged lip epithelium. Different types of lasers are used for this lip condition. In a clinical study, researchers combined carbon dioxide laser with pulsed dye laser therapy on actinic cheilitis lesions. It concluded that the combination therapy is a useful tool in the treatment of lip actinic chelitis. It was seen in another study that laser completely cleared AC in 92.5% patients with a very low rate of transformation (to cancer) and low recurrence rate.
Cryotherapy:
Another method of removing precancerous growth is cryotherapy, which works by freezing the abnormal cells. This modality mostly works on treating focal areas of cheilitis.
Photodynamic Therapy (PDT):
Exposing skin lesions to specialized light after introducing a photosensitizer produces reactive oxygen species that kill the sun-damaged cells. PDT is a well-tolerated and efficacious modality.
Electrocautery:
It uses intense heat (from an electric current) to destroy the precancerous lip lesion. The therapy works in treating localized areas of actinic damage.
Surgery
In severe cases, doctors remove a part (or whole) of your lower lip border. The procedure is called vermilionectomy. With advanced, safe, and effective non-surgical options available nowadays, surgical excision is not commonly adopted. Moreover, surgery is cosmetically disfiguring despite the high efficacy rate.
Actinic Cheilitis Prevention
Individuals belonging to the risk groups can adopt these steps to keep the precancerous pathology at bay.
- Try to limit sunlight exposure, especially during peak solar times.
- Apply sunscreens and lip balms.
- Avoid smoking and drinking.
- Wearing wide-brimmed hats at work can also save you from actinic pathologies.
Final Word
Actinic cheilitis is a precancerous condition of the lower lip, commonly seen in people with outdoor jobs (sailors, farmers, fishermen, etc.). It arises due to excessive solar (UV light) exposure and has a high conversion rate into cancer (SCC). Mostly, patients are old men (60 to 70-year-olds). The lesions initially present with dryness and cracking of the lips (especially the lower lip), which later turn into discolored, razor-sharp lesions. The sand-papery cheilitis lesions are generally painless but can impart feelings of burning, soreness, and tenderness. In the advanced stage, lesions turn into leukoplakic (white), non-healing ulcers, which eventually become cancers.
You should not ignore a bleeding ulcer or an ulcer that does not heal within 2-4 weeks, as it may be indicative of cancer. In addition to outdoor workers, smokers, drinkers, the aged, and fair-skinned people (and albinos) have a higher chance of acquiring the disease. First-line treatment therapy is the topical application of chemotherapeutic agents (like 5-fluorouracil, imiquimod, and trichloroacetic acid). Minimally invasive strategies like laser therapy, photodynamic therapy, cryotherapy, and electrocautery have been proven to be safe, well-tolerated, and pretty effective in managing actinic cheilosis. Usually, a combination of different strategies works for most patients. Vermilionectomy surgery is reserved for severe cases. Timely diagnosis and treatment are crucial in preventing conversion into malignancy.
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