International Journal of Health Sciences and Research

www.ijhsr.org ISSN: 2249-9571

Case Report

Actinic Cheilitis: A Case Report with Review of

Literature
Dr. M. Chandrasekhar, Dr. Marisetty Charitha, Dr. Ayesha Thabassum,
Dr. G. Chandrasekhar, Dr. Shalini
Department of Oral Medicine & Radiology, Government Dental College, Kadapa. Andhra Pradesh.
Corresponding Author: Dr. M. Chandrasekhar

ABSTRACT
Actinic cheilitis (AC) is a chronic inflammatory disorder that occurs mainly on the lower lip in the
susceptible individuals.[1] It is usually caused by chronic and excessive exposure of the lips to solar
ultraviolet (UV) radiation. The lesion is potentially malignant and may transform into squamous cell
carcinoma (SCC).[2] Clinical features include diffuse and poorly demarcated atrophic, erosive or
keratotic plaques that may affect some parts of, or the entire vermilion border. People with fair
complexion, engaged in more amount of outdoor activities and with eversion of lips are more
commonly affected by Actinic cheilitis.[3] Prophylactic measures against Actinic cheilitis must include
limitation of prolonged exposure to sunlight, the use of appropriate protective clothing, and the use of
a sunscreen cream. This is a case report of actinic cheilitis, its clinical features and treatment options.
Keywords: Actinic cheilitis, UVB, Squamous cell carcinoma.

INTRODUCTION actinic cheilosis, and cheilitis exfoliativa.

Actinic cheilitis (AC) is a chronic Here we present a case report, a case of
inflammatory disorder of the lips that actinic cheilitis in a 45 year old female.
exclusively occurs on the vermillion regions
of the lower lip. It is caused due to regular CASE REPORT
and prolonged exposure to sunlight in A 45 year old female patient came to
susceptible individuals. Actinic cheilitis is the Department of Oral Medicine and
derived from the Greek words “aktis” Radiology, Government dental college and
meaning “ray” and “cheilos” meaning hospital, Kadapa with the chief complaint of
“lips.”[1] It is considered as a potentially pain in the lower lip since 1 month. Patient
malignant lesion by the world health was apparently normal before 2 months
organization (1997).[2] This may lead to the after she developed encrustations and pain
development of SCC. The labial mucosa is in the lower lip, which was insidious in
more prone to dysplastic alterations by solar onset, initially small sized which gradually
radiation which is due to the fact that it is increased and attained the present size, pain,
more exposed to the environment and hence burning and tingling sensation was also
more susceptible to various disorders present. On inspection encrustations were
compared to the upper lip. The vermilion present on the lower lip, two in number,
border is more subjected to the effects of extending on the vermillion border of the
UV rays because of thinner epithelium, low lower lip, 1.5x1cm & 0.5x0.5 cms in size
melanin content, less sebaceous and sweat each on the right and left half of the lower
secretion.[3] Other names of actinic cheilitis lip respectively, roughly oval in shape,
include solar keratosis, actinic keratosis, Margins are well defined, edges are rolled

International Journal of Health Sciences & Research (www.ijhsr.org) 402

Vol.9; Issue: 6; June 2019
 M. Chandrasekhar et al. Actinic Cheilitis: A Case Report With Review Of Literature

out, floor of the ulcer is covered with found in dark-skinned people of India.[7] In
granulation tissue with erythematous a study conducted by Cavalcante et al, in
borders, surrounding mucosa was 2008 he stated that Actinic cheilitis is not
pigmented, crusted along the periphery. On exclusive to fair-skinned individuals. There
palpation the lesion is tender with no is a high incidence of actinic cheilitis in
bleeding on application of pressure, attached Somalia, where most of the inhabitants of
to the deeper structures, rolled out margins the country were black. He also inferred that
present. men and women are equally effected by
Based on the history and clinical Actinic cheilitis as they both share similar
findings it has been provisionally diagnosed working environment.[1,8] Risk factors for
as actinic cheilitis. A differential diagnosis Actinic cheilitis include outdoor activity and
of traumatic ulcer, cheilitis glandularis, skin type. Other factors such as smoking
erythema multiforme was also included. The and dietary habits, genetic predisposition are
patient was then subjected to hematological believed to be associated with carcinoma of
investigations like complete blood picture, lip. Exposure to sunlight associated with
HIV, HbsAg, HCV. other factors such as smoking and dietary
habits might produce a synergistic effect.
DISCUSSION Actinic cheilitis initially occurs as an
Skin is the organ most exposed to asymptomatic dry lip affecting the lower lip
environmental sunlight. Sunlight consists of vermilion. Advanced lesions may manifest
radiation that varies in wavelength from 200 as parallel folds or fissures, a loss of
to 1800 nm. Ultraviolet (UV) B rays which normally distinct cutaneous vermilion
range from 290 to 320 in wavelength, cause border, mottling, keratotic plaques, and
the superficial burning of the skin that leads erosions. The attack frequently begins with
to sunburn.[4] Lauren Marot et al, in 2008 a group of vesicles on the vermillion surface
has stated that The role of UVB in tumor of the lower lip, which soon becomes
induction has been accepted for decades and confluent, crusted, and scaling inflammation
the contribution of UVA has been ignored sometimes with swelling. In a study
for a long time. UV B rays are primarily conducted by Markopoulos et al, He found
responsible for sun-induced changes in the that Actinic cheilitis manifested clinically in
lip. Several studies have now provided three forms; white non ulcerated lesions,
substantial evidence of UVA involvement in erosions of ulcers of lip, mixed white non
the development of tumours and in the erosive.[9] Kaugars et al. found that on
depression of immune functions.[5] In a palpation, these lesions give the sense of
study conducted by Agar s et al, in 2006 gloved sliding finger on fine sand paper. [10]
stated that the predominance of UVA Actinic cheilitis may appear clinically with
mutations in the basal cell layer reinforces localized or diffused lesions. Markopoulos
the pivotal role UVA may play in the et al, in his study inferred that patients with
malignant transformation of human skin. lip cancer have lesions >1.0cm in diameter
Hence it is important to protect the at the time of their initial diagnosis. [9] Hence
population not just from UVB but also from the early diagnosis of actinic cheilitis is very
UVA irradiation, as it has profound crucial.
implications on public health.[6] Actinic Martinez et al found that epithelial
cheilitis affects the lower lip exclusively expression of P53 and murine double
because of its anatomic orientation that minute (mdm2) gene was significantly
exposes it to sunlight. It occurs in people increased in Actinic cheilitis.[10] Freitas et al,
who are habitually associated to sunlight in his study concluded that the expression of
such as farmers, peddlers, golfers. It was P53 and MDM2 proteins in Actinic cheilitis
believed that Actinic cheilitis most can be an important indicator in lip
commonly in fair-skinned people, it is also carcinogenesis, regardless of the degree of

International Journal of Health Sciences & Research (www.ijhsr.org) 403

Vol.9; Issue: 6; June 2019
 M. Chandrasekhar et al. Actinic Cheilitis: A Case Report With Review Of Literature

epithelial dysplasia.[12] Yanamoto et al, injection of alpha interferon are also being
studied in his study in 2002 confirmed a tested for its efficacy in treating Actinic
correlation between the super expression of cheilitis.
the MDM2 protein and an unfavourable
prognosis for the disease.[13] Actinic cheilitis CONCLUSION
is a potentially malignant lesion that affects Actinic cheilitis deserves a special
the lower lip and is caused by excessive attention because of its malignant potential.
exposure to solar radiation. The malignant The intimate association of the disorder with
transformation rate of actinic cheilitis into exposure to sunlight is an important factor
squamous cell carcinoma (SCC) of the lip to be noted in the history. Careful clinical
ranges from 10% to 30%.SCC of the lip is examination and recording the occupation is
common form of oral cancer corresponding the key to diagnose actinic cheilitis. Early
to 95% of all oral malignant lesions. Actinic diagnosis is of paramount importance as
cheilitis is thus a primarily UVB induced actinic cheilitis has the susceptibility to
intra epithelial neoplasm. And the mutations convert into squamous cell carcinoma and
induced by UVB can cause squamous cell therefore may deteriorate the prognosis of
carcinoma. the treatment outcome. Preventive measures
Diagnosis of the case is by clinical should always be followed when exposure
examination and history of exposure to sun. to sun cannot be avoided. Chemical and
In this case the patient was a shepherd physical sunscreens will help to lower the
which causes prolonged exposure to risk of damage caused by radiation to the
sunlight. As there was no deleterious habit skin. In this case the patient had everted
reported and trauma from the opposing lower lip due to which the there was direct
tooth was also ruled out, a diagnosis of exposure of sunlight making it more
actinic cheilitis was made. susceptible to hazardous effects of radiation.
Treatment options for actinic Moreover her occupational history revealed
cheilitis include prophylactic measures like prolonged outdoor activity. This case gives
avoiding exposure to sun , covering the skin us an insight into the importance of clinical
surfaces from sun light using a cap , and examination combined with occupational
applying sunscreen lotions with relevant sun history, the synergistic combination of
protection factors .treatment should be which helps us to arrive to the diagnosis.
aimed not only for discomfort and Hence early intervention can be done so as
disfigurement but also for potential to prevent harmful outcomes like squamous
malignancy. The treatment options available cell carcinoma that may cause unfavorable
for actinic cheilitis can be broadly divided prognosis to the patient.
into surgical and non surgical methods.
Surgical treatment includes
electrodessication, cryosurgery, and laser
treatment. Non surgical treatment includes
topical chemotherapy with antineoplastic
agent 5-fluorouracil or the
immunomodulator imiquimod chemo
exfoliation and dermabrasion. It has recently
been reported that photodynamic therapy
using the methyl-ester of aminolevulinic
acid as a photosensitizing agent is a very
effective treatment modality for actinic
cheilitis. It is well tolerated by patients and
provides excellent cosmetic outcomes.[14] Figure 1. Showing profile of the patient.
Topical / systemic retinoids, intra lesional

International Journal of Health Sciences & Research (www.ijhsr.org) 404

Vol.9; Issue: 6; June 2019
 M. Chandrasekhar et al. Actinic Cheilitis: A Case Report With Review Of Literature

2. MacFarlanc GE, Terezhalmy GT et al,: Actinic

chelitis: Diagnosis,prevention , and
treatment.US Navy Med 73:22, 1982.
3. Wood NH, Khamissa R, Meyerov R, Lemmer J,
Feller L et al, Actinic chelitis: A case report and
a review of the literature. Eur J Dent
2011;5:101-106.
4. Gomes A.P.N , Johann J.E, Lovato G.G, Ferreira
A.M et al, Comoaritive analysis of the mast cell
density in normal oral mucosa, Actinic cheilitis
and Lip squamous cell carcinoma. Braz Dent
J(2008) 19(3): 186-189.
5. Laurent Marrot, Jean-Roch Meunier, Aulnay-
sous-Bois et al: Skin DNA photodamage and its
Figure 2. Showing right lateral profile of the patient. biological consequences J Am Acad Dermatol
2007;58:S139-48.)
6. Agar N.S , Halliday GM, Barnettson RS,
Ananthaswamy HN, Wheeler M, Jones M et al,
The basal layers in human squamous tumor
harbours more UVA than UVB finger print
mutations : A role for UVA in human skin
carcinogenesis, PNAS 2004,vol.101,no.14.
7. Elogavan samasundaram et al, Actinic chelitis :
a review J indaian Acad Oral Med Radiol
2015;27:569-71.
8. Goracci G, Colangelo G, Nini G et al: Incidenza
delle chelitis attiniche in Somalia. Riv Ital
Somatol 50:1009, 1981.
9. Markopoulos A, Albanidou-Farmaki E, Kayavis
Figure 3. Showing encrustations on the lower lip. I. Actinic chelitis: clinical and pathologic
characteristics in 65 cases. Oral
Dis. 2004;10:212–216.
10. Kaugars GE, Pillion T,Svirsky JA,Page DG,
Burns JC,Abbey LM. Actinic chelitis: A review
of 152 cases.Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 1999:88:181-186.
11. Martinez A,Brethauer U,Rojas IG,Spencer M,
Mucientes F,Borlando J,et al.Epithelial
expression of apoptotic and cell proliferation
regulatory proteins in actinic chelitis. J Oral
Pathol Med. 2005;34(5):257-62.
12. Freitas, Ramalho ,Xavier ,Moreira ,Reis et al,
Figure 4: Showing encrustations on the lower lip. p53 and MDM2 protein expression in actinic
chelitis.J Appl Oral Sci.2008;16(6):414-9.
REFERENCES 13. Yanamoto S, Kawasaki G, Yoshitomi I, Mizuno
1. Cavalcante A.S.R, Anbinder A.L, Carvalho Y.R A.p53,mdm2, and p21 expression in oral
et al, Actinic cheilitis clinical and histological squamous cell carcinomas: Relationship with
features 2008 American Association of Oral and clinicopathologic factors. Oral Surg Oral Pathol
Maxillofacial Surgeons J Oral Maxillofac Surg Oral Radiol Endod. 2002; 94(5):593-600.
66:498-503, 2008. 14. Rossi R,Assad GB,Buggiani G,Lotti
T.Photodynamic therapy:treatment of choice for
actinic chelitis? Dermatol ther2008; 21:412-415.

How to cite this article: Chandrasekhar. M, Charitha. M, Thabassum. A. et al. Actinic cheilitis: a
case report with review of literature. Int J Health Sci Res. 2019; 9(6):402-405.

******

International Journal of Health Sciences & Research (www.ijhsr.org) 405

Vol.9; Issue: 6; June 2019