Monday, September 18, 2017

Cheilitis Query

September 2017
The patient is a 70 yo Caucasian who has lived on Moorea, French Polynesia, for the past 50 years.  She contacted us recently about her painful lips because there is no dermatologist available to her at present.  Here is her anamnesis:
In early July when I went to Montreal, my lips started to bother me. I thought maybe it was 18 hours on a plane, or even maybe it was a sunburn from being in the pool with my grandchildren in sunny Vancouver a couple weeks before. It didn't subside and I bought several lip therapies - cocoa butter, Vaseline, Aquaphor. When I came home I used a mild steroid ointment for a couple weeks, but to no effect. I now carry Aquaphor with me all the time and apply it constantly. Chapstick with SPF (from a friend in the States) stings my lips, as does toothpaste. My lips are not chapped, as in flaky or peeling, but they feel and look burnt, even blistery sometimes, and they can feel severely tight, dry and very sore. Actually, my upper lip is not as involved as my lower lip, and the corners are not affected. 

Photo sent by patient to VGRD

Diagnosis: This appears to be actinic cheilitis or possibly allergic/irritant cheilitis.  Strangely,  the patient got more sun in Vancouver than she does in French Polynesia!

What are your thoughts?

Update (April 2018):
(from the patient) I want to share with you the results of a recent experiment I conducted unwittingly. Our daughter was visiting Tahiti for the last week, and we went to the beach several days in a row. Although I wore a hat and Vanicream lip sunscreen, I got too much sun and my lower lip has been on fire. I think actinic cheilitis was an early guess last year, and I have NO DOUBT that it was correct. I'm using Vaseline, of course, and the betamethasone dipropionate ointment after nothing else worked. I'm happy not to be puzzled, confused and freaked out this time around.  Note:  I think we may be dealing with a case of actinic prurigo of the lips (see references 3 and 4 below)


1. Actinic cheilitis: a treatment review.
Shah AY, Doherty SD, Rosen T.
Abstract:  All other factors being equal, the presence of actinic cheilitis, a pre-invasive malignant lesion of the lips, doubles the risk of squamous cell carcinoma developing in this anatomic area. Various forms of local ablation, immunomodulation and surgical extirpation have been proposed as therapeutic interventions. This paper critically evaluates the available medical literature to highlight the evidence-based strength of each recommended therapy for actinic cheilitis. Vermilionectomy remains the gold standard for efficacy; trichloroacetic acid application is easy and convenient, but the least efficacious overall.

2. Contact allergy in cheilitis.
O'Gorman SM, Torgerson RR. Int J Dermatol. 2016 Jul;55(7):e386-91.
BACKGROUND: Recalcitrant non-actinic cheilitis may indicate contact allergy.
CONCLUSIONS: Contact allergy is an important consideration in recalcitrant cheilitis. Fragrances, antioxidants, and preservatives dominated the list of relevant allergens in our patients. Nickel and gold were among the top 10 allergens. Almost half (45%) of these patients had a final diagnosis of ACC. Patch testing beyond the oral complete series should be undertaken in any investigation of non-actinic cheilitis.

3. Actinic Prurigo Cheilitis: A Clinicopathologic Review of 75 Cases.
Plaza JA, et al. Am J Dermatopathol. 2016 Jun;38(6):418-22.

4. Actinic prurigo of the lip: Two case reports.
Miranda AM. World J Clin Cases. 2014 Aug 16;2(8):385-90. Free Full Text.

1 comment:

  1. Hi David thanks for the post and i would consider a lip bx to separate the possible diagnoses 1.actinic dermatitis 3. lichen planus , lupus erythematosus 4. factitial . Please let us know . Regards Chris Tyson .


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