Clinicopathological profile and management of 161 cases of actinic cheilitis

Clinicopathological Analysis of Actinic Cheilitis: A Systematic Review with Meta-analyses

BACKGROUND

This systematic review aimed to conduct a complete investigation of the demographic aspects, clinicopathological features, degrees of epithelial dysplasia, and malignant transformation rate of actinic cheilitis.

METHODS

The study was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in the International Prospective Register of Systematic Reviews (CRD42020201254). A search without year and language restrictions was performed using PubMed/MEDLINE, Embase, Virtual Health Library, Scopus, Web of Science, and gray literature. Studies that provided information on patients with actinic cheilitis were included, excluding those with general information on other diseases or other types of cheilitis. Risk of bias was explored using the Joanna Briggs Institute tool. Narrative and quantitative data syntheses were performed using meta-analyses and subgroup analyses. Association tests were also performed.

RESULTS

Thirteen studies (728 patients) were included. The most prevalent clinical signs were dryness (99%), blurred demarcation between the lip vermilion and skin (82%), scaling (69%), and atrophy (69%). Regarding epithelial dysplasia, a prevalence of mild dysplasia (34.2%), followed by moderate (27.5%), and severe (14.9%). The malignant transformation rate was 14%. Crusts, ulcerations, and erythematous areas were associated with lip carcinoma (p < 0.001), and scaling was associated with actinic cheilitis (p < 0.001).

CONCLUSIONS

This study revealed several features of actinic cheilitis, providing an overview of the disease. It is suggested that new studies help develop policy guides for the standardization of clinical criteria, enabling more rigorous and homogeneous analysis of actinic cheilitis.

Factors Participating in the Occurrence of Inflammation of the Lips (Cheilitis) and Perioral Skin

Lip inflammation may manifest as mainly reversible cheilitis, mainly irreversible, or cheilitis connected to dermatoses or systemic diseases. Therefore, knowing a patient’s medical history is important, especially whether their lip lesions are temporary, recurrent, or persistent. Sometimes temporary contributing factors, such as climate and weather conditions, can be identified and avoided—exposure to extreme weather conditions (e.g., dry, hot, or windy climates) may cause or trigger lip inflammation. Emotional and psychological stress are also mentioned in the etiology of some lip inflammations (e.g., exfoliative cheilitis) and may be associated with nervous habits such as lip licking. To better manage cheilitis, it is also helpful to look for potential concomitant comorbidities and the presence of related diseases/conditions. Some forms of cheilitis accompany dermatologic or systemic diseases (lichen, pemphigus or pemphigoid, erythema multiforme, lupus, angioedema, xerostomia, etc.) that should be uncovered. Occasionally, lip lesions are persistent and involve histological changes: actinic cheilitis, granulomatous cheilitis, glandular cheilitis, and plasmacellular cheilitis. Perioral skin inflammation with simultaneous perioral dermatitis can have various causes: the use of corticosteroids and cosmetics, dysfunction of the skin’s epidermal barrier, a contact reaction to allergens or irritants (e.g., toothpaste, dental fillings), microorganisms (e.g., Demodex spp., Candida albicans, fusiform bacteria), hormonal changes, or an atopic predisposition. Epidermal barrier dysfunction can worsen perioral dermatitis lesions and can also be related to secondary vitamin or mineral deficiencies (e.g., zinc deficiency), occlusive emollient use, sunscreen use, or excessive exposure to environmental factors such as heat, wind, and ultraviolet light. Current trends in research are uncovering valuable information concerning the skin microbiome and disruption of the epidermal barrier of persons suffering from perioral dermatitis. Ultimately, an effective approach to patient management must take all these factors and new research into account.

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.

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.

Immunoexpression of PD-L1, CD4+ and CD8+ cell infiltrates and tumor-infiltrating lymphocytes (TILs) in the microenvironment of actinic cheilitis and lower lip squamous cell carcinoma

Lower lip squamous cell carcinomas (LLSCC) could be associated with a previous history of potentially malignant oral diseases (PMOD), especially actinic cheilitis (AC), with high sun exposure being a well-described risk factor. Immune evasion mechanisms, such as the PD-1/PD-L1 (programmed cell death protein 1/programmed death-ligand 1) pathway has been gaining prominence since immunotherapy with immune checkpoint inhibitors showed a positive effect on the survival of patients with different types of neoplasms. Concomitant with the characterization of the tumor microenvironment, the expression of either or both PD-1 and PD-L1 molecules may estimate mutual relations of progression or regression of the carcinoma and prognostic values of the patient.

Clinical and dermatoscopic predictors of squamous cell carcinoma of the lips: a case-control, multicentric study

BACKGROUND

Squamous cell carcinoma of the lip accounts for 20% of all oral carcinomas. Its diagnosis may be challenging because it clinically resembles actinic cheilitis and inflammatory lesions of the lips.

OBJECTIVES

To determine clinical and dermatoscopic predictors of squamous cell carcinoma of the lip vs. other lip lesions.

METHODS

Multicentre retrospective morphological study, including histologically confirmed cases of squamous cell carcinoma of the lip and controls consisting of actinic cheilitis and inflammatory lesions of the lips. Clinical and dermatoscopic images were evaluated for the presence of predefined criteria. Crude and adjusted odds ratios and corresponding 95% confidence intervals were calculated by univariate and multivariate logistic regression respectively.

RESULTS

A total of 177 lip lesions were evaluated, 107 (60.5%) were squamous cell carcinomas and 70 (39.5%) were controls. The most frequent dermatoscopic criteria of lip squamous cell carcinoma were scales (100%), white halos (87.3%) and ulceration (79.4%). The majority of squamous cell carcinomas displayed polymorphic vessels (60.8%), with linear (68.6%) and hairpin (67.6%) being the most frequent types. Multivariate logistic regression analysis showed that clinical predictors of lip squamous cell carcinoma were exophytic appearance and clinical hyperkeratosis, with 43-fold and 6-fold higher probability respectively. White clods and ulceration in dermoscopy presented a 6-fold and 4-fold increased risk for squamous cell carcinoma respectively.

CONCLUSIONS

A scaly lesion with exophytic growth, dermatoscopically displaying white clods, ulceration and linear and hairpin vessels is very likely a squamous cell carcinoma of the lip.

Use of Lip Protecting Agents in the Prevention of Actinic Cheilitis, Herpes Labialis and Cancer of Lip: A Systematic Review

Background:

Actinic cheilitis, herpes labialis and lip cancer are relatively common conditions presenting on the lips associated with exposure to periods of sun exposure and thereby ultraviolet radiation.

Objective:

This systematic review aimed to determine the efficacy of the application of sunscreen-containing lip-protecting agents (LPA) in the prevention of actinic cheilitis (AC), recurrent herpes labialis (RHL) and lip cancer (LC).

Methods:

This review was conducted in accordance with the PRISMA guidelines and registered with the PROSPERO database. A literature search was conducted using SCOPUS, Google Scholar, Medline (Ovid), Pubmed, CINAHL, Cochrane Library databases and manual search using search terms actinic cheilitis (AC), recurrent herpes labialis (RHL) and lip cancer (LC) along with lip protecting agents and their variations as keywords. A total of 1,567 papers were yielded. Of them, nine studies were eligible for qualitative data synthesis.

Results:

Nine articles (3 AC, 5 RHL, 1 LC) were deemed eligible and thus selected for qualitative synthesis. Three studies on AC identified approximately 21.7% lower prevalence of lesions when some form of lip protection was used. Eighty percent of studies on RHL identified that the application of LPA is effective in preventing RHL. Subjects who applied LPA more than once daily only had half the risk of having LC compared to those who applied once daily.

Conclusion:

This review of randomised controlled trials (RCTs) and observational studies supports the use of LPA as an effective method in preventing lip-associated lesions. Further, RCTs and observational studies should aim at determining a definitive LPA application regime and optimal SPF strength to prevent lip-associated lesions.

This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO): Registration Number - CRD42020177484. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020177484

Treatment Options and Post-Treatment Malignant Transformation Rate of Actinic Cheilitis: A Systematic Review

Simple Summary

Actinic cheilitis is a precancerous condition that may evolve to a more aggressive type of skin cancer. Therefore, its therapy is crucial for the disease prognosis. In this systematic review, we tried to identify the best therapies of actinic cheilitis regarding safety, efficacy, recurrences, and the potential to progress to skin cancer. The therapeutic approach comprised invasive and topical treatments. The invasive therapies, such as partial surgery and laser treatments, had the best cosmetic and therapeutic results with few recurrences. Photodynamic therapy demonstrated satisfactory outcomes, while topical treatments were the least beneficial. Notably, the efficacy of photodynamic therapy was improved when combined with 5% imiquimod. However, except from photodynamic therapy, the other modalities were assessed in a limited number of patients. Finally, when actinic cheilitis is treated, no risk of cancer progression exists. Larger studies are necessary to confirm these results.

Abstract

Actinic cheilitis is a premalignant condition that may evolve to squamous cell carcinoma. A consensus on its management has not been established, and large clinical trials are lacking. We aimed to review the existing data regarding the treatment of actinic cheilitis with various modalities regarding safety, efficacy, recursions, and post-treatment malignant transformation. A systematic review was conducted through Pubmed, Ovid and the Cochrane library for studies in English language and the references of included papers from inception to January 2021. Case series were considered if ≥6 patients were included. Of the 698 articles, 36 studies and, overall, 699 patients were eventually reviewed. Laser ablation and vermilionectomy provided the best clinical and aesthetic outcomes with few recurrences, while photodynamic therapy was linked to more relapses. Generally, the adverse events were minor and there was no risk of post-treatment malignant transformation. The limitations of our review include the heterogeneity and the small number of patients across studies. Conclusively, invasive treatments demonstrated superior therapeutic and safety profile. Nevertheless, high-quality head-to-head studies that assess different modalities for actinic cheilitis and report patient preferences are lacking.

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.

Oral Potentially Malignant Disorders and Oral Cavity Cancer

The Surveillance, Epidemiology, and End Results program from the National Cancer Institute reports that the aggregate number of oral cavity and pharyngeal cancer cases has been increasing over the past decade and, despite an overall decline in oral cavity cancers, this increase is largely related to a dramatic increase in cancers involving oropharyngeal subsites. Early detection of oral cavity cancers is commensurate with improved survival, and opportunistic screening by trained clinicians to detect oral cavity cancer and oral potentially malignant disorders is recommended by the American Dental Association and the American Academy of Oral Medicine.

In Vivo Reflectance Confocal Microscopy-Diagnostic Criteria for Actinic Cheilitis and Squamous Cell Carcinoma of the Lip

Actinic cheilitis (AC) is one of the most frequent pathologies to affect the lips. Studies show that the most commonplace oral malignancy, squamous cell carcinoma (SCC), often emerges from AC lesions. Invasive diagnostic techniques performed on the lips carry a high risk of complications, but reflectance confocal microscopy (RCM), a non-invasive skin imaging technique, may change the current diagnostic pathway. This retrospective study was aimed at consolidating the RCM diagnostic criteria for AC and lip SCC. The study was conducted in two tertiary care centers in Bucharest, Romania. We included adults with histopathologically confirmed AC and SCC who also underwent RCM examination. Of the twelve lesions included in the study, four were AC and eight were SCC. An atypical honeycomb pattern and the presence of target cells in the epidermis were RCM features associated with AC. SCC was typified by the presence of complete disruption of the epidermal architecture and dermal inflammatory infiltrates. The mean blood vessel diameter in SCC was 18.55 µm larger than that in AC (p = 0.006) and there was no significant difference (p = 0.64) in blood vessel density, as measured by RCM, between SCC and AC. These data confirm that RCM can be useful for the in vivo distinction between AC and lip SCC.

Daylight photodynamic therapy for the management of actinic cheilitis

Early identification and adequate treatment of actinic cheilitis (AC), which affects the lower lip vermillion and is considered a precursor of squamous cell carcinoma, is mandatory. Photodynamic therapy (PDT) has been successfully used in AC. PDT with the use of daylight (DLPDT) is equally effective and more convenient than the conventional PDT. Data on short and long-term efficacy of DLPDT in AC are limited. Our primary purpose was to assess efficacy of DLPDT in AC as well as safety and tolerance. Twenty-two individuals with histologically confirmed AC received 2 MAL (5-aminolevulinic acid)-DLPDT sessions 1 week apart. Patients were evaluated clinically 3, 6, and 12 months after treatment. Non-complete responders were biopsied and excluded from the study if histological alterations were indicative of AC. Adverse events were recorded from baseline to the end of the 12-month follow-up period. Twenty patients completed the study. Overall, complete clinical response 12 months after treatment was 80% (16/20), while an association between treatment response and grade of dysplasia was observed (p = 0.016). With respect to response by grade, complete clinical response achieved in grade I AC was 100% (12/12) and 50% (4/8) in grade II AC. Main adverse events included mild erythema, oedema, and scaling, with no pain associated with DLPDT. According to our results, DLPDT seems to be of significant benefit for the treatment of grade I AC. Combination with the other treatment modalities could improve the efficacy in grade II AC. Further studies are needed for the assessment of late recurrences.

Demographic and Clinicopathologic Features of Actinic Cheilitis and Lip Squamous Cell Carcinoma: a Brazilian Multicentre Study

Data on the occurrence and clinicopathological characteristics of actinic cheilitis (AC) and lip squamous cell carcinoma (LSCC) are well studied; however, they are based on studies limited to a single centre. Herein, we described the frequency of AC and LSCC submitted to microscopic examination from representative geographic regions of Brazil. A retrospective multicentre study was performed on biopsies obtained from 1953 to 2018 at 10 Brazilian oral and maxillofacial pathology centres. A total of 198,709 biopsy specimens were surveyed. Sociodemographic data and clinicopathologic characteristics were analysed. A total of 2017 cases of ACs (1.0%) and 850 cases of LSCCs (0.4%) were recorded. A strong fair-skinned (> 87%) male (> 70%) predilection was observed in both conditions. The mean age was 54.8 ± 18.7 for individuals with AC and 57.8 ± 19.0 for individuals with LSCC. The most commonly affected site was the lower lip (> 90%). This is a large multicentre study of AC and LSCC from Brazil. The frequency and clinicopathological features of AC and LSCC were similar to those described worldwide. This study provides robust and representative epidemiological data of these conditions for the scientific community.

Actinic cheilitis: Morphometric parameters and its relationship with the degree of epithelial dysplasia

Actinic cheilitis (AC) is a potentially malignant lesion caused by chronic sun exposure. This study aimed to evaluate the relationship between the degree of epithelial dysplasia and morphometric findings in AC. Sixty-eight slides of AC cases were selected and classified according to the grade of epithelial dysplasia, following morphologic criteria of World Health Organization. For morphometric analysis, the slides were scanned and images were analyzed using Pannoramic Viewer software. We obtained vertical measurements of the parameters: thicknesses of the keratin layer, lamina propria and zone of solar elastosis in three selected fields. Thirty-seven (54.4%) of the analyzed cases were classified as none/mild dysplasia and 31 (45.6%) as moderate/severe epithelial dysplasia. Cases with a moderate/severe dysplasia exhibited a thicker layer of keratin (median = 0.055 mm) than none/mild dysplasia (median = 0.045 mm) (p = 0.033). No significant differences in the thicknesses of lamina propria and zone of solar elastosis were observed according to the grade of epithelial dysplasia. A positive significant correlation between keratin layer and lamina propria thicknesses was found (p = 0.019). Based on our findings, rigorous clinical follow-up should be recommended for patients whose histopathological examination shows a greater thickness of the keratin layer.

Fludroxycortide cream as an alternative therapy for actinic cheilitis

OBJECTIVES

The objective of the study is to assess, by clinical follow-up, the efficacy of the dermatological cream Fludroxycortide 0.125 mg/g (Drenison®) in the treatment of actinic cheilitis (AC).

MATERIAL AND METHODS

Twenty-three patients diagnosed with AC participated in the study. Fifteen were submitted to corticotherapy with Fludroxycortide, applied three times a day for up to 6 weeks, associated with lip sunscreen (LS) before sun exposure. In the control group of eight patients, only the use of LS was established. At each weekly return, a photographic record was made of the lesion. After treatment, images were evaluated and scores were assigned to verify clinical evolution. Also, patients treated with Fludroxycortide responded to a questionnaire, to assess drug tolerability and treatment satisfaction.

RESULTS

In the group treated with Fludroxycortide (n = 15), five patients showed total improvement, seven presented partial improvement, and three showed no clinical change. Concerning the patients treated with LS (n = 8), one presented total remission of the clinical lesion characteristics, four exhibited partial improvement, and three exhibited no clinical lip alteration. No case presented symptom worsening. Of the 15 patients undergoing corticotherapy, 12 were satisfied and reported that the product was not irritating and contributed to lesion improvement.

CONCLUSIONS

Conventional treatment with LS was effective in the remission of some AC lesions, but treatment responses were improved when associated with Fludroxycortide, especially in the more severe cases.

CLINICAL RELEVANCE

As it is a non-invasive therapy leading, in most cases, to adequate clinical results, safety, and tolerability, Fludroxycortide can be considered an effective alternative treatment for AC.

Actinic cheilitis and lip squamous cell carcinoma: Literature review and new data from Brazil

Background

To investigate the prevalence of malignant and potentially malignant lesions of the lip in an oral pathology service and to compare these data with a literature review.

Material and Methods

A total of 3173 biopsy reports and histopathological records were analyzed. Cases with a histological diagnosis of actinic cheilitis (AC) with or without epithelial dysplasia, in situ carcinoma, or lip squamous cell carcinoma (LSCC) were included. A comprehensive literature review was conducted to investigate the prevalence of AC and/or LSCC.

Results

124 cases (3.91%) were included, 75 (60.5%) had some degree of epithelial dysplasia and 31 (25.0%) were LSCC. Clinically, most of the lesions were diagnosed as AC (50.8%); however, eight cases clinically reported as AC were histologically diagnosed as LSCC. Regarding clinical characteristics, most individuals were fair-skinned male, with mean age of 54.3±12.3 years, and with a history of long-term solar exposure. Furthermore, 18 articles were selected from the literature, showing that the lower lip was predominantly affected and that most individuals were males, fair-skinned, and older than 40 years.

Conclusions

Since most of the cases diagnosed clinically as AC presented some degree of epithelial dysplasia, it is important to emphasize the value of biopsy and the histological evaluation of this lesion.

Key words:Actinic cheilitis, Precancerous conditions, In situ carcinoma, Oral diagnosis, Mouth neoplasms.

Surgical versus non-surgical treatment of actinic cheilitis: A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review was to compare outcomes between surgical and non-surgical treatment of actinic cheilitis (AC).

MATERIALS AND METHODS

A systematic review and meta-analysis based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses guideline were performed. A search of PubMed/MEDLINE, Web of Science, and Cochrane Library databases was conducted. Articles were selected based on the inclusion criteria: randomized clinical trials, prospective/retrospective studies, and case series with at least 10 patients, with a minimum follow-up period of 6 months. A weighted remission rate (RER) and recurrence rate (RR) with a 95% confidence interval was performed. Data analysis was performed using a comprehensive meta-analysis software.

RESULTS

A total of 283 ACs in 10 studies were included. About 2.5% surgically treated cases underwent malignant transformation. The weighted remission rate was higher for surgical (92.8%) compared to non-surgical treatment (65.9%). The recurrence rate was lower for surgical (8.4%) compared to non-surgical treatment (19.2%).

CONCLUSION

In this systematic review, the surgical treatment was more favorable than non-surgical for AC. Meanwhile, further studies are needed that should maximize methodological standardization and have greater rigor of the data collection process.

Immune response and evasion mechanisms in lip carcinogenesis: An immunohistochemical study

OBJECTIVES

Programmed death ligand-1 (PD-L1) and human leukocyte antigen-G (HLA-G) are considered immune checkpoint molecules that inhibit T-cell effectiveness, contributing to tumor immune escape. This study investigated PD-L1, HLA-G, CD8, and granzyme B (GrB) expression at different stages of lip carcinogenesis.

DESIGN AND RESULTS

Forty cases of lip squamous cell carcinoma (LSCC), 55 actinic cheilitis (AC), and 10 healthy lip mucosa (HLM) were submitted to immunohistochemistry. Semiquantitative (PD-L1, HLA-G), and quantitative (CD8, GrB) analysis were performed. PD-L1 and HLA-G expression in neoplastic cells/keratinocytes and stroma/connective tissue was significantly higher in LSCC and AC, compared to HLM (p<0.05). PD-L1 was not associated with clinicopathological features of the lesions. HLA-G expression by malignant cells was significantly higher in LSCCs with distant metastasis (p = 0.041).CD8⁺ and GrB⁺ cell numbers progressively increased from HLMs to LSCC, with AC exhibiting intermediate numbers (p<0.01). Most LSCCs showed coexistence of PD-L1⁺ and CD8⁺ cells (72.5%). PD-L1 was directly correlated to CD8⁺ and GrB⁺ lymphocytic infiltration in LSCCs (p<0.05). Low cytotoxic immune response was associated with lymph node metastasis in LSCC (p<0.05).

CONCLUSIONS

PD-L1 and HLA-G-mediated immune evasion mechanisms are likely to occur from early pre-malignant to advanced malignant stages of lip carcinogenesis, which might provide a rationale for therapeutic blockade of these pathways. PD-L1 expression in LSCCs was correlated with the cytotoxic markers, suggesting that PD-L1 may appear as an escape mechanism in response to an active antitumor response.

Daylight photodynamic therapy for the treatment of actinic cheilitis

BACKGROUND

Actinic cheilitis (AC) is a common, chronic premalignant condition resulting from protracted sun exposure affecting the vermilion border of the lower lip. Treatment of AC aims at terminating the progression to squamous cell carcinoma by obliterating the primary lesion, and includes ablative methods; nonablative modalities such as cryotherapy, electrodessication, chemical peeling, topical imiquimod and 5-fluorouracil; and photodynamic therapy (PDT). Daylight-activated PDT, in which natural daylight serves as the light source, showed promising results in the treatment of actinic keratoses with substantially less pain than conventional PDT.

PURPOSE

To determine the safety and efficacy of daylight PDT in a series of patients with AC.

METHODS

Eleven patients with AC were treated with daylight PDT. All patients underwent repeated treatment sessions until clinical and histological remission were achieved.

RESULTS

Cure rate was 91% (10 of 11 patients, three females/eight males; mean age 59.2 ± 14.4 years). Mean number of treatments to attain cure was 2.7. Patients experienced mild erythema and minimal to no pain during treatment.

CONCLUSIONS

Daylight PDT is a promising modality for the treatment of AC, with impressive cosmetic results and few side effects.

Non-invasive imaging of actinic cheilitis and squamous cell carcinoma of the lip

An early diagnosis is of overwhelming importance for the management and prognosis of mucocutaneous cancer. Actinic cheilitis (AC), defined by the clonal expansion of genomically unstable keratinocytes, is the most common potentially malignant lesion affecting the lips. Squamous cell carcinoma (SCC) is the most frequent oral malignancy, and there is strong evidence that the majority of the SCCs of the lip originate from AC. There is considerable difficulty in discerning between dysplasia and invasive carcinomas solely on a clinical basis. Although dermoscopy has become an essential tool for skin tumor evaluation, reflectance confocal microscopy (RCM) is a non-invasive imaging technology that has proved itself extremely useful in the diagnosis and monitoring of several skin diseases, including AC and SCC. The present study aimed to re-emphasize the usefulness of RCM in the early detection of malignant transformation, using AC and SCC of the lips as working examples. Due to the apparent innocuousness of AC for numerous patients, it is not possible to overstress the importance of a correct and early diagnosis, proper treatment and long-term patient follow-up as being essential for preventing the progression to lip SCC, or for its timely diagnosis.

Prevalence of and Factors Associated with Actinic Cheilitis in Extractive Mining Workers

Abstract The objective of the present study was to determine the prevalence of actinic cheilitis among extractive mining workers and factors associated with the condition, especially the relationship between clinical appearance and the length of occupational exposure to sunlight. A cross-sectional study was performed in Dona Inês, Paraíba, Brazil between 2014 and 2015. A clinical examination, clinical photography and a questionnaire were applied to 201 extractive mining workers. The T-student’s, ANOVA one-way, Fisher’s exact and Pearson chi-squared tests were performed and the significance level was set at 5%. A high prevalence of actinic cheilitis was observed (38.8%). Length of occupational exposure to sunlight in months (169.63±112.68, p=0.002) was associated with actinic cheilitis. Most workers were Caucasian (p<0.001) and aged 37.41±12.15 years (p=0.004). The time of occupational exposure to sunlight was significant in relation to the following clinical features: atrophy (225.75±97.31; p=0.024); blurred demarcation between the vermilion border of the lip and the skin (186.68±113.15; p=0.032); vertical fissures (210.09±123.07; p=0.046); white and red spotting (199.51±91.80; p=0.004); hard consistency of the lip (225.81±122.34; p=0.012). A high prevalence of actinic cheilitis was found. Age and ethnicity were associated with the presence of AC. Severe clinical presentations of actinic cheilitis were found among participants who had worked for at least 185 months (approximately 15 years) exposed to the sun.

Management of actinic keratosis at specific body sites in patients at high risk of carcinoma lesions: expert consensus from the AKTeam™ of expert clinicians

Actinic keratoses (AK) arise on sun-exposed regions of the skin. If left untreated, AK may progress to invasive squamous cell carcinoma (SCC), although the rate of progression is low. A practical treatment algorithm for the treatment of AK in standard situations has been published by the AKTeam^™ expert panel. However, management of particular situations of AK with increasing/higher carcinoma risk or AK progressing into carcinomas with increased aggressiveness due to their anatomical location (risky areas), or in patients with an increased risk of SCC requires further discussion. These include AK on the dorsal hands, forearms, legs, periorbital region, eyelids, ears, or lips, and organ transplant recipients, patients undergoing treatment with carcinogenic agents and patients with chronic lymphocytic leukaemia. The main objective was to propose therapeutic strategies for the treatment of AK located in risky areas and in patients with more invasive/aggressive lesions and a higher risk of progression to SCC. A systematic review of the literature was initially performed, and results were discussed by the experts to propose best management practices in specific situations. Finally, adapted management strategies for AK occurring in risky areas and in high-risk patients are presented, taking into account the experts' own clinical experience and current guidelines. In most of these 'at-risk' situations, patients can be treated according to the AKTeam^™ treatment algorithm. Difficult-to-treat lesions should be treated more aggressively due to their higher risk of transformation. For patients with skin that is highly susceptible to actinic damage, monitoring and sun protection strategies are mandatory, and patients should undergo more regular follow-up. Further assessment of newer therapies in clinical trials is necessary to determine optimal treatment conditions. This expert consensus provides guidance for the management of AK in risky body sites and in patients with an increasing/higher risk for SCCs.

Diclofenac sodium gel therapy as an alternative to actinic cheilitis

OBJECTIVE

Actinic cheilitis (AC) is a potentially malignant lesion caused by prolonged exposure to ultraviolet light. The aim of this research was to analyze the efficacy of diclofenac sodium 3% gel in the treatment of this condition, through clinical follow-up.

METHODS

Thirty-one patients diagnosed with AC were instructed to perform a topical application of the gel three times a day for a period of 90 days. In each visit, a digital photography was obtained for verified progress and response to treatment. Two researchers evaluated all images after treatment was completed and assigned the following scores regarding clinical aspect of the lip: 1, complete improvement; 2, partial improvement; 3, no changes; 4, worsening of the clinical condition. In addition, the patients' tolerability to the drug and their satisfaction after treatment were evaluated.

RESULTS

Twelve cases abandoned the treatment for reasons unrelated to the study. Ten participants showed total remission of all clinical features of the lesion and three had partial improvement of the characteristics. One participant presented worsening of clinical condition, and in five cases, treatment was discontinued due to development of mild adverse effects at the site of gel application. Regarding satisfaction analyses and tolerability to the drug, from 14 patients who completed treatment without adverse effects or complications, most agreed fully that they were satisfied with the therapy (n = 11) and that the drug was not irritating to the mouth (n = 9). Patients are being monitored without clinical signs of recurrence and/or progression of the lesions.

CONCLUSION

Topical application of the drug has provided a convenient and well tolerated in most cases.

CLINICAL RELEVANCE

Diclofenac sodium gel (3%) may be a promising alternative for treatment of actinic cheilitis.