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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 26  |  Issue : 1  |  Page : 107-110

Actinic cheilitis with a familial pattern: An unusual case


1 Department of Oral Medicine and Radiology, SB Patil Dental College, Bidar, India
2 Department of Oral Medicine and Radiology, Navodaya Dental College, Raichur, Karnataka, India
3 Department of Pedodontics, St. Joseph Dental College, Eluru, Andhra Pradesh, India
4 Department of Oral Medicine and Radiology, Sri Sai College of Dental Sciences, Vikarabad, Telangana, India

Date of Submission16-Jun-2014
Date of Acceptance03-Sep-2014
Date of Web Publication26-Sep-2014

Correspondence Address:
Surekha Murthi
c/o Hasya Dental Care, E Seva Lane, MIG 72, III Phase, KPHB Colony, Hyderabad - 500 072, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.141875

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   Abstract 

Actinic cheilitis is a chronic inflammatory disorder of the lip, affecting the lower lip mainly, caused by cumulative long-term effects of ultraviolet (UV) radiation in sunlight. It is a premalignant condition with a malignancy potential of 6-10%. It is reported that it almost exclusively occurs in fair-skinned people and those who work outdoors. However, it has recently been reported that actinic cheilitis is not exclusive to fair-skinned people. It is most common in middle-aged or older male patients. Diagnosis of actinic cheilitis is mainly based on demographical, clinical, and histopathological findings. Factors such as socioeconomic status, smoking, dietary habits, and genetic predisposition are also associated with lip cancer. Here, we present a case of actinic cheilitis in two siblings and in their mother, showing a familial pattern. An incisional biopsy of the lower lip in the mother showed severe dysplastic changes indicating transformation to squamous cell carcinoma.

Keywords: Actinic cheilitis, elastosis, ultraviolet radiation


How to cite this article:
Murthi S, Thayi SR, Konidala U, Chappidi V. Actinic cheilitis with a familial pattern: An unusual case . J Indian Acad Oral Med Radiol 2014;26:107-10

How to cite this URL:
Murthi S, Thayi SR, Konidala U, Chappidi V. Actinic cheilitis with a familial pattern: An unusual case . J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2020 Jan 22];26:107-10. Available from: http://www.jiaomr.in/text.asp?2014/26/1/107/141875


   Introduction Top


Long-term exposure of lips to ultraviolet (UV) light from sunlight causes a lesion known as actinic cheilitis (AC). In tropical countries, exposure to sunlight can be more harmful, especially during outdoor activities. AC is reported to be more prevalent in fair-skinned people, who work outdoors, and in middle aged or older individuals. [1] Clinically it presents as erythema, swelling of lips, erosion and even ulceration, with poor demarcation between the lip vermillion and skin. Histologically it is characterized by elastosis, chronic inflammatory infiltrate, and vasodilation. [1] Diagnosis is mainly based on the demographic data, clinical presentation, and histopathological features. [2]

Actinic cheilitis is considered to be a premalignant condition with a malignant potential of 6-10%, [3] and therefore, needs special attention. Routine dental examination should also include examination of the facial skin and lips. Although genetic predisposition is reported to be one of the risk factors, there are no case reports in literature about the occurrence of AC in families. Here we report a case of actinic cheilitis in two siblings, with their mother having carcinoma in situ of the lower lip.


   Case Report Top


A 42-year-old, dark-skinned, female patient, who worked as a daily laborer, came to the Department of Oral Medicine and Radiology, in May 2009, accompanied by her daughter and son, with a chief complaint of burning sensation and cracking of lips since six to seven months. The burning pain was continuous and moderate. Pain was aggravated on exposure to sunlight. Her daughter and son also complained of a burning sensation in the lower lip since two months. On clinical examination, the patient had incompetent lips with a slightly everted lower lip [Figure 1]. There was an irregular area of erosion in the middle of the lower lip extending from the vermillion border to the skin of the lip [Figure 2]. The lip was tender to touch and the vermillion border was indurated. A single submandibular lymph node on the right and left side and one submental lymph node were palpable, which were nontender, mobile, and firm in consistency.
Figure 1: Mother with incompetent lips

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Figure 2: Lower lip showing central erosion with cracking and scaling

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Considering the patient's occupation, age, skeletal features, and clinical presentation a provisional diagnosis of actinic cheilitis was made and an incisional biopsy was performed. The histopathological report was suggestive of carcinoma in situ with loss of stratification of the epithelium, individual cell keratinization, hyperchromatic nuclei, and loss of polarity confined to the epithelium [Figure 3] and [Figure 4]. The patient was managed surgically in an oncology unit with vermillionectomy, followed by mucosal advancement.
Figure 3: Microscopic view (10x) of the biopsy specimen showing epithelial thinning with tear-drop shaped rete pegs

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Figure 4: Microscopic view (high power) of the biopsy specimen showing loss of stratification of the epithelium, individual cell keratinization, and loss of polarity confined to the epithelium. Hyperchromatic nuclei are also evident

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On clinical examination of the siblings, both had dry and cracking lips [Figure 5] and [Figure 6]. Considering the clinical findings and its occurrence in the siblings, they were diagnosed as suffering with hereditary polymorphic light eruption. Both the siblings were advised to minimize sun exposure and advised to use sunscreens when outdoors.
Figure 5: Daughter showing dry cracked lower lip

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Figure 6: Son showing dry cracked lower lip

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   Discussion Top


Actinic cheilitis refers to a degenerative premalignant condition of the lips. [4] The link between lip cancer and sunlight was first noted in 1923. [5] The most important risk factor for actinic cheilitis is outdoor activity and skin type. Also socioeconomic status, lifestyle, smoking, dietary habits, and genetic predisposition are associated with lip cancer. [1] It has also been reported that chronic recurrent actinic cheilitis associated with hereditary polymorphic light eruption appears to be a specific characteristic of photosensitivity occurring in American Indians. [6] Although many studies reported that AC is prevalent in fair-skinned people, a recent study has demonstrated that it is not exclusive to fair-skinned individuals. [2] Apart from these risk factors, dental and skeletal characteristics like a prognathic maxilla also contribute to more exposure of lips to sunlight. [1] In the presented case also, the patient had dark complexion with other risk factors like outdoor activity and bimaxillary protrusion. Ultraviolet-B radiation of sunlight, with the wavelength ranging from 290-320 nm, causes superficial burning of the skin and is responsible for sun-induced changes of the lip. [5] The lip has less protection than the skin because the epithelium is thinner, lacks thicker keratin, has less melanin, and fewer secretions from the sebaceous and sweat glands. [4] The lower lip is more commonly affected due to the angle of the UV rays striking the vermillion surface. In the present case, the patient has incompetent lips with a slightly everted lower lip, which also contributed to the direct exposure of the lip to sunlight.

Actinic cheilitis presents clinically as a localized or diffuse lesion of the lips that may be white, red or red and white. White areas represent areas of hyperkeratinization, whereas, red areas represent areas of atrophy. Lips appear dry with erythema, sometimes with swelling and cracking. Demarcation between the lip vermillion and skin is blurred. In the later stages ulceration also appears. A burning or itching sensation is the presenting symptom. In the presented case, all the typical features suggestive of AC were present except for the absence of ulceration. The siblings were also complaining of a recurrent burning sensation and dryness of the lips suggestive of actinic cheilitis. As both the siblings were presenting with actinic cheilitis, it was suggestive of hereditary polymorphic light eruption. As the degree of clinical change was not necessarily related to the amount of either epithelial or connective tissue change, [5] biopsy was advised in this case and the histopathological report was suggestive of carcinoma in situ, with severe dysplastic changes confined to the epithelial layer. Actinic cheilitis is considered by some authors to be a very superficial incipient form of actinically induced squamous cell carcinoma of the lower lip. [7] It has been reported that lip malignancies are more prone to metastasize compared to skin cancer, with rates varying from 3-20%, however, the prognosis is better compared to intraoral cancers. [8]

The most effective protection against sun damage is the use of sun screens and reducing sun exposure. As AC with severe dysplasia must be treated by vermillionectomy, we referred the patient to the oncology unit. Other recommended treatments for AC are CO 2 laser, cryotherapy, topical 5-flourouracil or retinoid or photodynamic therapy.


   Conclusion Top


Any lip lesion, even though it appears benign, should prompt the clinician to perform a biopsy, to identify any dysplastic changes and prevent further morbidity or mortality. The predisposition of other family members to these actinic changes must be considered, and also, there is a scope for genetic studies in these patients.

 
   References Top

1.Cavalcante AS, Anbinder AL, Carvalho YR. Actinic cheilitis: Clinical and histological features. J Oral Maxillofac Surg 2008;66:498-503.  Back to cited text no. 1
    
2.Markopoulos A, Albanidou-Farmaki E, Kayavis I. Actinic cheilitis: Clinical and pathologic characteristics in 65 cases. Oral Dis 2004;10:212-6.  Back to cited text no. 2
    
3.Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 2 nd ed. Philadelphia: Saunders Elsevier; 2002. p. 353-4.  Back to cited text no. 3
    
4.Bentley JM, Barankin B, Lauzon GJ. Paying more than lip service to lip lesions. Can Fam Physician 2003;49:1111-6.  Back to cited text no. 4
    
5.Kaugars GE, Pillion T, Svirsky JA, Page DG, Burns JC, Abbey LM. Actinic cheilitis: A review of 152 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:181-6.  Back to cited text no. 5
    
6.Birt AR, Hogg GR. The actinic cheilitis of hereditary polymorphic light eruption. Arch Dermatol 1979;115:699-702.  Back to cited text no. 6
[PUBMED]    
7.Menta Simonsen Nico M, Rivitti EA, Lourenço SV. Actinic cheilitis: Histologic study of the entire vermillion and comparison with previous biopsy. J Cutan Pathol 2007;34:309-14.  Back to cited text no. 7
    
8.Abreu MA, Silva OM, Neto Pimentel DR, Hirata CH, Weckx LL, Alchorne MM, et al. Actinic cheilitis adjacent to squamous carcinoma of the lips as an indicator of prognosis. Braz J Otorhinolaryngol 2006;72:767-71.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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