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Actinic cheilitis treatment with ablative laser vermilionectomy

Actinic cheilitis treatment with ablative laser vermilionectomy

Actinic cheilitis is a precancerous condition of the lip caused by long-term sun exposure. It is characterized by whitish or grayish discoloration and hyperkeratotic changes, which often blunt the demarcation point between the mucosa and skin of the lower lip (Figure 1). It is not known exactly how often this condition may eventuate into squamous cell carcinoma, but the concern is certainly present. It is known, however, that squamous cell carcinoma of the lip has a higher risk of recurrence as well as metastasis compared to other cutaneous sites.1

before

after

Figure 1A. A 77-year-old Caucasian male with actinic cheilitis demonstrating significant areas of grayish and hyperkeratotic changes on the lower lip mucosa. 1B. Results 2.5 months after 1 laser vermilionectomy session with ablative erbium resurfacing (Sciton Profile, Sciton Corporation). Photos courtesy of Joel L. Cohen, MD, FAAD

Therapeutic Options

Actinic cheilitis treatment options cover the spectrum of topical therapies to surgical and light-based procedures — but, similar to other medical conditions, they each have their own pros and cons. As for topical therapies, none are actually FDA approved for this condition and research on utilization specifically for actinic cheilitis is scarce. One concern regarding topical therapies to the lip is potentially heightened absorption through the mucosa, at least theoretically leading to high serum levels and systemic sequelae. These may include gastrointestinal symptoms (abdominal pain, diarrhea etc) in some patients with dihydropyrimidine dehydrogenase deficiency when using topical 5-fluorouracil products or flu-like symptoms with topical imiquimod. A newer medication, ingenol mebutate, has some early adopter physicians recommending it for actinic cheilitis as well, but as with other sites there can be a very robust inflammatory response with this medication and some patients may have very significant scabbing and crusting.

Aside from topical therapies, other treatment options include diffuse cryotherapy to the lower lip, trichloroacetic acid peel, photodynamic therapy — especially with activation by a pulsed-dye laser,2 laser vermilionectomy and surgical vermilionectomy with mucosal advancement. In our practices, we commonly employ laser vermilionectomy procedures for the treatment of actinic cheilitis. The patients seen for this condition typically fall into 3 main groups: (1) those with clinical evidence of grayish-hyperkeratotic multifocal patches with no areas of breakdown of the mucosa; (2) those who have had a biopsy on an area of mucosal breakdown and crusting that reveals only actinic cheilitis (with full visualization of the base of the lesion) and no evidence of squamous cell carcinoma; and (3) those who have recently had a squamous cell carcinoma on the lower lip removed with surgical techniques and grayish-hyperkeratotic changes are visible in  other areas on that lower lip. 

While all abovementioned treatment modalities could be utilized, all have pros and cons that need to be considered, though no comparative studies exist to help a physician decide on a specific choice. Cryotherapy may not provide consistent depth of penetration and also leads to blister formation and scabbing. Photodynamic therapy usually does not have as robust a reaction as cryotherapy, but often requires several treatments.2 Topical therapy, such as imiquimod, can be very effective, but, in addition to the abovementioned flu-like symptoms, may also lead to aphthous ulcers.3 Surgical vermilionectomy requires uniform distal excision of the entire lower lip, and leads to a lot of discomfort, swelling and potential asymmetry and pulling of the lower lip intra-orally from the tethering to the gingival sulcus.

Laser Vermilionectomy

Laser vermilionectomy can be a very effective therapy that offers controlled depth of penetration to selected microns, though, similar to these other destructive therapies, leads to a significant healing response often lasting 5-7 days. 

Ablative laser vermilionectomy procedures can be performed with either an ablative erbium or CO2 laser.  While CO2 laser is often used in literature, it is associated with extensive thermal damage zone, typically not necessary for the treatment of superficial conditions, such as actinic cheilitis. On the other hand, a 2940-nm erbium laser permits easy recognition of the treatment endpoint of pinpoint bleeding and allows for a precise depth of epithelial ablation. The most common settings we use are 3-5 passes with depth of ablation of 40-50 microns (corresponding to fluences of 10-12.5 J/cm2), paying close attention to the endpoint of diffuse pinpoint bleeding (Figure 2B). More hyperkeratotic areas may require additional passes to reach this endpoint than others.

lips before

lips b

lips c

Figure 2A. A 48–year-old woman with clinical actinic cheilitis Figure 2B. Immediate post-erbium (Sciton Profile. California, USA) laser vermilionectomy after 3 passes at 50 microns with an endpoint of pinpoint bleeding. Figure 2C. At 3-months follow-up, showing improvement in the grayish patchy discoloration of the mucosal lower lip. Photos courtesy of Joel L. Cohen, MD, FAAD

Many patients respond to a single laser vermilionectomy treatment, though a second treatment is sometimes needed to clear more significant cases of actinic cheilitis. We usually obtain pretreatment photos, to be followed 2 months later by posttreatment photos for comparison and to determine if additional treatments are necessary. Regardless of treatment modality, follow-up is recommended at least every 6 months to monitor for any evidence of recurrence or progression to squamous cell carcinoma.

 Dr. Taylor is a dermatologist and cosmetic laser surgeon at the Gateway Aesthetic Institute and Laser Center in Salt Lake City, UT.

Dr. Cohen is the director of AboutSkin Dermatology and DermSurgery in Colorado. His practice focuses on Mohs surgery and cosmetic dermatology.

Dr. Berlin is president of DFW Skin Surgery Center, PLLC, in Arlington, TX. He is also a Clinical Assistant Professor of Dermatology at the New Jersey Medical School in Newark, NJ.

Disclosure: Related to lasers and light-based technology, Dr. Cohen has worked with Palomar, Candela and Sciton. Dr. Berlin and Dr. Taylor have no disclosures to report.

 References

1. Jadotte YT, Schwartz RA. Solar cheilosis: an ominous precursor: part I. Diagnostic insights. J Am Acad Dermatol 2012;66(2):173-184.

2. Alexiades-Armenakas MR, Geronemus RG. Laser-mediated photodynamic therapy of actinic cheilitis. J Drugs Dermatol 2004;3(5):548-551.

3. Chakrabarty AK, Mraz S, Geisse JK, Anderson NJ. Aphthous ulcers associated with imiquimod and the treatment of actinic cheilitis. J Am Acad Dermatol. 2005;52(2 Suppl 1):35-37.

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