Treatments of actinic cheilitis: A systematic review of the literature

Interdisciplinary management of skin cancer

The interdisciplinary treatment of skin cancer in the head and neck area requires close collaboration between different specialist disciplines. The most common non-melanoma skin cancer tumor entities are cutaneous squamous cell carcinoma and basal cell carcinoma as well as their precursor lesions. One of the less common tumors is Merkel cell carcinoma, which also occurs primarily in light-exposed areas and, in contrast to squamous and basal cell carcinoma, is more likely to metastasize. Due to the low tendency of basal cell carcinoma as well as cutaneous squamous cell carcinoma to metastasize, a cure can often be achieved by surgery. If the tumor growth exceeds certain levels it may require collaboration between dermatology and otorhinolaryngology. The primary goal of this interdisciplinary collaboration is to achieve a functional, cosmetically and aesthetically acceptable result in addition to adequate tumor treatment. Depending on the stage of the tumor and the clinical course, a case may be discussed in an interdisciplinary tumor board in order to determine a personalised, appropriate and adequate treatment concept for each patient, including prevention, therapy and follow-up.

A Review of the Dermatologic Clinical Applications of Topical Photodynamic Therapy

Topical photodynamic therapy is a widely approved therapy for actinic keratoses and low-risk nonmelanoma skin cancers with a rapidly growing range of emerging indications for other cutaneous diseases. This review summarizes the best-available evidence to provide a clinical update for dermatologists on the approved and emerging indications of photodynamic therapy. The body of evidence suggests that photodynamic therapy is superior or noninferior to other available treatment modalities for actinic keratoses, low-risk basal cell carcinomas, Bowen's disease, skin field cancerization, chemoprevention of keratinocyte carcinomas in organ transplant recipients, photoaging, acne vulgaris, and cutaneous infections including verrucae, onychomycosis, and cutaneous leishmaniasis. There is emerging evidence that photodynamic therapy plays a role in the management of actinic cheilitis, early-stage mycosis fungoides, extramammary Paget disease, lichen sclerosis, and folliculitis decalvans but there are no comparative studies with other active treatment modalities. Common barriers to topical photodynamic therapy include procedural pain, costs, and the time required for treatment delivery. There is significant heterogeneity in the photodynamic therapy protocols reported in the literature, including different photosensitizers, light sources, number of treatments, time between treatments, and use of procedural analgesia. Topical photodynamic therapy should be considered in the management of a spectrum of inflammatory, neoplastic, and infectious dermatoses. However, more comparative research is required to determine its role in the treatment algorithm for these dermatologic conditions and more methodological research is required to optimize photodynamic therapy protocols to improve the tolerability of the procedure for patients.

Outcomes of Squamous Cell Carcinoma of the Lip Treated With Mohs Micrographic Surgery: A Retrospective Cohort Study

BACKGROUND

Cutaneous squamous cell carcinomas (cSCCs) of the lip have been reported to be at higher risk for poorer post-treatment outcomes.

OBJECTIVE

To examine outcomes of patients with SCC of the lip treated with Mohs micrographic surgery (MMS) and identify factors for recurrence.

MATERIALS AND METHODS

This retrospective review of a single tertiary referral center's Mohs case logs from 2010 to 2019 identified cases of lip SCC. Clinicopathologic characteristics and outcomes (local recurrence [LR], metastasis, and disease-specific death) were reviewed.

RESULTS

One hundred ninety cases of SCC of the lip were identified and demonstrated that MMS offered a disease-free survival of 96.8% over an average follow-up period of 42 months. Younger age (61 vs 74 years p = .006), increased MMS stages ( p = .009), and higher American Joint Committee on Cancer and Brigham and Women's Hospital T stages were risk factors for LR. Immunosuppression, large tumor size, mucosal lip involvement, aggressive histology, and perineural invasion were not associated with LR.

CONCLUSION

The results of this study show that SCC of the lip behaved similarly to cSCC outside the lip area, and that both primary and recurrent lesions can be treated effectively with MMS.

Topical and Intralesional Immunotherapy for the Management of Skin Cancer in Special Locations: Lips and Eyelids

The use of topical and intralesional immunotherapy in the treatment of cutaneous malignant neoplasia in sensitive areas such as the lips and eyelids is discussed. Surgery may not be feasible or may result in deformities in these areas, making alternative treatment options necessary. A narrative literature review was conducted using MEDLINE (PubMed) as the main literature database, collecting available evidence of experiences with various topical and intralesional therapies in the aforementioned anatomical locations, ranging from case reports to clinical trials. The clearance rates and potential adverse reactions of therapeutic options such as imiquimod 5%, 5-fluorouracil (5-FU), photodynamic therapy (PDT), ingenol mebutate (IM), diclofenac, intralesional methotrexate, and interferon are reviewed. Although limited by their heterogeneity and the scarcity of clinical trials, these studies point towards promising response rates and minimal adverse effects, making these treatments viable options in selected cases.

Revisiting the evidence of photodynamic therapy for oral potentially malignant disorders and oral squamous cell carcinoma: an overview of systematic reviews

BACKGROUND

This study summarized the available evidence about the use of photodynamic therapy (PDT) for the management of oral potentially malignant disorders (OPMD) and oral squamous cell carcinoma (OSCC).

METHODS

An overview of systematic reviews was undertaken based on the 2020 PRISMA statement. Electronic searches were performed in five databases. Studies published up to November 2022 were included. Risk of bias was assessed with the AMSTAR 2 tool.

RESULTS

A total of 30 studies enrolling 9,245 individuals with OPMD (n=7,487) or OSCC (n=1,758) met the selection criteria. All studies examined the efficacy and/or safety of PDT. OPMD were investigated individually in 82.8% of the studies, the most common being oral lichen planus and actinic cheilitis. OSCC was addressed separately in 10.3% of the studies, while only 6.9% evaluated both OPMD and OSCC. Fourteen different types of photosensitizers were described. PDT was used according to the following setting parameters: 417-670 nm, 10-500 mW/cm², 1.5-200 J/cm², and 0.5-143 minutes. Regarding OPMD, leukoerythroplakia showed the best response rates, while oral lichen planus presented a partial or no response in nearly 75% of documented cases. A complete response was observed in 85.9% of OSCC cases, while 14.1% had no resolution.

CONCLUSION

Overall, the response to PDT depended on the type of OPMD/OSCC and the parameters used. Although PDT is an emerging candidate for the treatment of OPMD and OSCC, there is heterogeneity of the methodologies used and the clinical data obtained, particularly regarding the follow-up period.

Lower lip basal cell and squamous cell carcinomas: a reappraisal of the similarities and differences in clinical presentation and management

Basal cell carcinoma and squamous cell carcinoma are the two most common types of carcinomas, affecting a total of 5.4 million people each year in the United States. Sun-exposed areas, especially the face and nose, are most affected given the strong association between these carcinomas and ultraviolet radiation. Less research has been done surrounding carcinomas of the lip, despite the significant aesthetic and functional importance of this area. Although lip carcinomas tend to follow a classic, unique distribution pattern that favors basal cell carcinoma on the upper lip and squamous cell carcinoma on the lower lip, more cases of lower lip basal cell carcinoma are being reported, warranting further educational awareness to differentiate carcinomas of the lower lip. In this article, we provide an updated overview of the risk factors, presentations, differential diagnoses, metastatic risks, evaluation, management guidelines, and outcomes of lower lip carcinoma. Of note, recent advances in imaging modalities are beginning to show promise as a non-invasive, affordable, and rapid way to detect and stage tumors. We conclude that increased clinical awareness and investigation of lower lip carcinoma is needed to improve early intervention, as a delayed diagnosis can rapidly alter the management and outcomes of lip carcinomas.

Randomized Clinical Trial of Conventional versus Indoor Daylight Photodynamic Therapy for Treatment of Actinic Cheilitis

Introduction

Actinic cheilitis (AC) is the biologic precursor of invasive squamous cell carcinoma (SCC) of the vermilion, and different treatment options have been investigated, but their efficacy is hampered by local inflammation, pain and slow recovery. Daylight photodynamic therapy (dl-PDT) has been demonstrated to represent a valuable treatment option for AC, but its feasibility is limited by weather conditions and latitude.

Methods

Our study proposed to compare the efficacy and tolerability of conventional photodynamic therapy (c-PDT) and indoor daylight photodynamic therapy (idl-PDT) with a white LED lamp for the treatment of AC. Sixteen patients were enrolled in the study: 8 (50%) treated with c-PDT and 8 (50%) treated with idl-PDT. All patients completed the study protocol.

Results

Both idl-PDT and c-PDT were demonstrated to be highly effective in terms of reduction of the cumulative lesional area and severity of the clinical score. Neither treatment was inferior to the other. The inflammatory reaction and the pain scores were milder with idl-PDT, whereas the cosmetic outcome was not different.

Conclusion

The present findings confirm that idl-PDT can represent a valid therapeutic strategy for AC patients as well, despite the procedural difficulties and the risk of poor tolerability related to the body site.

A Review of Existing Therapies for Actinic Keratosis: Current Status and Future Directions

Actinic keratosis (AK) is a chronic skin disease in which clinical and subclinical cutaneous lesions coexist on sun-exposed areas such as the head and neck region and the extremities. The high prevalence of AK means the disease burden is substantial, especially in middle-aged and elderly populations. Evidence indicates that AK may progress into invasive cutaneous squamous cell carcinoma, so the European guidelines recommend treatment of any AK regardless of clinical severity. Given the aging population and therefore the increasing incidence of AK and cutaneous field carcinogenesis, further updates on the long-term efficacy of current therapies and new investigational agents are critical to guide treatment choice. Patients often have difficulty adequately applying topical treatments and coping with adverse local skin reactions, leading to less than optimum treatment adherence. The development of associated local skin symptoms and cosmetic outcomes for the area of interest are also relevant to the choice of an appropriate therapeutic strategy. Treatment is always individually tailored according to the characteristics of both patients and lesions. This review focuses on the therapeutic approaches to AK and illustrates the currently available home-based and physician-managed treatments.

Actinic Cheilitis - From Risk Factors to Therapy

Actinic cheilitis or solar cheilosis is considered a precursor of malignancy or even an in situ squamous cell carcinoma (SCC) of the lip, located most frequently on the lower lip. Actinic cheilitis (AC) has a higher likelihood of developing into invasive SCC of the lip, which is one of the deadliest non-melanoma skin cancers. Risk factors include chronic UV exposure, increasing age, male gender, fair phototypes, chronic scarring, immunosuppressive therapy, and tobacco use. From a clinical point of view, AC is characterized by dryness, scaling, atrophy, indistinct borders, and erosions. Ulceration and the appearance of a nodule often suggest the progression to invasive SCC. Dermoscopic examination reveals white structureless areas, scales, erosions, and white halos of the vermilion. Reflectance confocal microscopy shows disruption of the stratum corneum, parakeratosis, an atypical honeycomb pattern, solar elastosis, and dilated and tortuous blood vessels with increased blood flow. The rate of malignant transformation ranges from 10 to 30% and early diagnoses and treatment are essential in preventing the development of invasive SCC. Optimal treatment has not been established yet, but invasive and topical treatments can be tried. The present paper aims to review the existing data regarding epidemiology, risk factors, clinical picture, non-invasive imaging, diagnosis, and therapy in AC.

Efficacy of photodynamic therapy in actinic cheilitis: a systematic review

BACKGROUND

Photodynamic therapy (PDT) has gradually developed into a promising modality for actinic cheilitis (AC), and many new PDT strategies are emerging. However, comprehensive reviews evaluating the efficacy of PDT strategies for AC are lacking.

OBJECTIVE

To systematically review the safety and efficacy of PDT strategies for AC.

METHODS

A systematic review was conducted using three databases to compare several types of PDT for AC in terms of clinical response (CR), histopathology response (HR), cosmetic result, and adverse events.

RESULTS

A total of 19 studies were included, and 292 subjects were finally enrolled. The complete CR rate of ALA-patch PDT, traditional photodynamic therapy (T-PDT), and daylight photodynamic therapy (DL-PDT) was 80.00% (24/30), 65.14% (114/179), and 76.74% (33/43), respectively. The rate of painless patients was 87.10% (27/31) in DL-PDT, whereas the rate was only 31.25% (15/48) in T-PDT. The rates of moderate and severe local phototoxicity were 47.78% (43/90) in T-PDT, 0.00% (0/23) in DL-PDT, and 21.05% (4/19) in ALA-patch PDT.

CONCLUSION

Published literature suggests that ALA-patch PDT seem to achieve high complete CR rate. Besides, DL-PDT might be a well-tolerated therapy compared with T-PDT and ALA-patch PDT. However, these assumptions are made based on very limited data. It is necessary to conduct a long-term larger sample randomized controlled trial to further evaluate the efficacy and adverse events of various PDT schemes for AC.

Assembling a consensus on actinic cheilitis: A Delphi study

AIMS

To discuss the terminology to define and classify actinic cheilitis (AC) and to build a consensus on the diagnostic and therapeutic approaches to AC.

METHODS

Two-round Delphi study using a questionnaire including 34 closed sentences (9 on terminology and taxonomy, 5 on potential for malignant transformation, 12 on diagnostic aspects, 8 on treatment) and 8 open questions. Experts' agreement was rated using a Likert scale (1-7).

RESULTS

A consensus was reached on 24 out 34 statements (73.5%) and on 5 out of 8 (62.5%) close-ended questions. The response rate was identical in both rounds (attrition of 0%). AC is the term with the highest agreement (median of 7 (strongly agree; IQR: 6-7)) and the lowest dispersion (VC = 21.33). 'Potentially malignant disorder' was the preferred classification group for AC (median of 7) and 85.6% of participants showing some level of agreement (CV < 50). Experts (66.75%) consider AC a clinical term (median: 7; IQR: 4-7) and believe definitive diagnosis can be made clinically (median: 6; IQR: 5-7), particularly by inspection and palpation (median: 5; IQR: 4-6). Histopathological confirmation is mandatory for the management of AC (median: 5; IQR: 2.5-7), even for homogeneous lesions (median: 5; IQR: 3.5-6). Consensus was reached on all treatment statements (VC < 50).

CONCLUSIONS

AC is a potentially malignant disorder with a significant lack of agreement on diagnostic criteria, procedures, biopsy indications and the importance of techniques to assist in biopsy. A consensus was reached on nomenclature and management of this disorder.

Use of topical anti-inflammatory and antineoplastic agents in the treatment of young-aged actinic cheilitis: A systematic review

INTRODUCTION

Several treatments have been used to reduce inflammation and to reverse epithelial alterations in actinic cheilitis (AC).

AIM

A systematic review was conducted to analyze the potential of topical treatments for remission and clinical improvement of AC as well as patient acceptability.

METHODS

A systematic review of clinical trials was conducted following the PICO strategy to answer the following question: Are topical anti-inflammatory and antineoplastic agents effective in the treatment of actinic cheilitis? The quality of the studies was assessed by ROB-2, and the certainty of evidence was rated by GRADE guidelines.

RESULTS

Eight clinical trials were selected, including four that investigated the use of anti-inflammatory drugs and four use of antineoplastic agents. The use of 3% diclofenac sodium was associated with partial remission of AC, while 5% imiquimod and ingenol mebutate promoted complete remission. Furthermore, 5% fluorouracil was the drug most associated with complications during treatment. Diclofenac sodium (3%) and fludroxycortide showed the best acceptance by the patients, especially in terms of symptom relief and comfort provided.

CONCLUSION

The anti-inflammatory and antineoplastic agents analyzed largely provided good clinical outcomes, with evidence of remission of AC lesions, development of few local adverse reactions during treatment, and good patient adherence.

Combination of Laser Therapy and Photodynamic Therapy with 5-Aminolevulinic Acid Patch for the Treatment of Actinic Cheilitis

Background: Actinic cheilitis (AC) is a premalignant lesion of the lips that can evolve into squamous cell carcinoma. Among nonsurgical treatments, photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA) patch might represent a new noninvasive therapeutic approach for AC. Objective: We sought to investigate the potential role of fractional CO₂ laser pretreatment in boosting ALA penetration and distribution into AC treated with PDT. Methods: We report a case of a woman with AC on the lower lip, treated with ablative fractional CO₂ laser to boost drug delivery of 5-ALA patch before PDT treatment. Reflectance confocal microscopy was performed to assess diagnosis and treatment response. Results: We detected a good clinical and cosmetic outcome after two applications of combined treatment. Erythema, crust, and edema were reported as side effects. Conclusions: This case report shows that ablative fractional CO₂ laser-assisted PDT might be an effective therapeutic alternative for patients with AC who refuse or are contraindicated for surgical procedures.

Actinic cheilitis: a systematic review of treatment options

Actinic cheilitis is a premalignant condition that can progress to squamous cell carcinoma with a higher propensity for metastasis than cutaneous squamous cell carcinoma. Optimal treatment for actinic cheilitis has not been established, and evidence-based estimates of clinical cure in the dermatology literature are limited. Here, we review and synthesize outcome data published for patients with actinic cheilitis after treatment with various modalities. A systematic review was conducted in MEDLINE, Embase and the Cochrane library for English, French and German-language studies and references of included articles from inception to 20 January 2020. Studies were included if they reported on at least six patients with biopsy-proven actinic cheilitis. After quality appraisal, results of studies with the strongest methodology criteria were synthesized. 18 studies of 411 patients (published 1985 to 2016) were included. The majority of the studies were case series. Carbon dioxide laser ablation and vermilionectomy were associated with the most favourable outcomes with fewest recurrences. Chemical peel and photodynamic therapy were associated with higher recurrence. Adverse effects generally resolved in the weeks following treatment and cosmetic outcomes were favourable overall. In conclusion, there is a lack of high-quality comparative studies evaluating different treatment options for actinic cheilitis. The included publications used various outcome measures; however, the majority reported on the recently defined core outcome sets. These results suggest that both carbon dioxide laser ablation and vermilionectomy are effective treatments for actinic cheilitis. Prospective head-to-head studies are needed to compare these treatment modalities and to assess patient preferences.