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Home , Actinic cheilitis

DERMATOLOGY - SUN CARE

SOFIA RAFAELA MAITO VELASCO, ADELSON FRANCISCO MAIA-JÚNIOR, JOSÉ ROBERTO DE MAGALHÃES BASTOS, ARIÁDNES NÓBREGA OLIVEIRA, MAGALI DE LOURDES CALDANA, ROOSEVELT SILVA BASTOS* *Corresponding Author Disciplina de Saúde Coletiva - Depto Odontopediatria, Ortodontia e Saúde Coletiva - Faculdade de Odontologia de Bauru, Universidade de São Paulo, Al. Dr. Octávio Pinheiro Brisolla 9-75, CEP 17012-901 - Bauru-SP, Brazil

Roosevelt Silva Bastos

Actinic and risk of : a short review of etiology and treatment

Actinic cheilitis is considered a carcinogenic injury. It is characterized by on the red edge of the Abstractlower as a white board and has a higher risk of incidence in Caucasian workers who are exposed to the sun often. The objective of this paper is to present a review of the risks involved in the etiology and progression of actinic cheilitis for squamous cell carcinoma. Once diagnosed, several treatments may be performed to contain its evolution, however, the emphasis on the need to alert people to the means of preventing the etiologic risk factors: self-examination of the and periodic consultations with a dentist and/or doctor.

INTRODUCTION turn would lead to and reduced protective capacity of the lips (8). Given that, the damage caused by solar Premalignant is a disease syndrome that may lead to radiation accumulates over the years and smoking increases the cancer. The term was proposed in 1875 by Romanian physician likelihood of lesion progression to malignancy (9). Victor Babes. Oral premalignant lesions are relatively common, Patients with actinic cheilitis should receive guidance about the occurring in about 2.5% of the population (1). Actinic cheilitis is injury in order to promote the best possible prevention, since considered a premalignant lesion, better known as carcinogenic there are necessary periodic tests to detect early malignant injury. It is a term used to describe degeneration and pre- transformation as soon as possible. The mainstay of treatment malignant changes that occur in the mouth. Actinic refers to the consists of surgery, but also chemotherapeutic agents have been chemically active electromagnetic spectrum and cheilitis refers to used with some success (topical 5-fl uorouracil), criocirurgias, infl ammation of the lips (2). vermilionectomy, photodynamic therapy, carbon dioxide, application of trichloroacetic acid, and others (10). However, when anon-surgical method is adopted, the monitoring should ACTINIC CHEILITIS be extended, as approximately 10% of these lesions will undergo malignant transformation (4). Actinic cheilitis is caused by solar radiation, occurring most commonly in Caucasians who work in open spaces (3), i.e. fair- skinned individuals whose occupation keeps them exposed to SQUAMOUS CELL CARCINOMA (farmers, sailors, fi shermen). It is characterized by lesions in the red edge of the lower lip as a white board in a linear fashion, The type of cancer is the most common oral squamous cell. oval, typically measuring less than 1 cm in size, but may also be Although easily detectable, oral cancers are often discovered observed in the skin of the forehead, cheeks, ears and lower arms late and 60% are eventually fatal (5). The incidence of cancer (4). The actinic cheilitis is considered potentially malignant disorder increases with age: the majority of oral cancers are found in to the development of squamous cell carcinoma of the lip patients aged between 50 and 70 years. The incidence of (5).Most commonly found in middle-aged men (40-80 years), squamous cell carcinoma increases with an increase in age. it may be the initial lesion in the progression of squamous Unfortunately, squamous cell carcinoma found in the oral cell carcinoma. Although controversial, itis often cited a rate mucosa, including labial mucosa, is more aggressive and more lower than 1/1000 per year (6). likely to metastasize than lesions elsewhere. Metastasis rates are light acts on tissue proteins and DNA in inducing higher than 14% for squamous lips than to the skin. mutations that initiate and promote dysplastic changes in the Inn general, carcinoma lesions become necrotic, protrude (7). In other words, it is a primary factor to induce centrally, and produce irregular ulcers. Squamous cell carcinoma changes in the lower lip due to their intense absorption by tends to metastasize to the lymph nodes and submental nucleic acids. Most of the damage caused by ultraviolet B submaxilar. The lips are considered an area of high risk for (UVB) radiation is due to changes which prevent transcription of developing cancer due to their chronic sun exposure, with genetic information for the mRNA, blocking the mechanism of the lower lip receiving maximum exposure. Other risk factors DNA replication, leading to decrease in mitotic activity, which in such as smoking and alcohol are associated with carcinoma;

16 H&PC Today - Household and Personal Care Today, Vol. 8 nr. 6 November/December 2013 nevertheless it is more specifi cally associated to actinic economic status, and poor diet (12). Additionally, the time cheilittis (4). All risk factors for also predisposes to of exposure to UV has not been quantifi ed by the literature, carcinoma. After the diagnosis of malignancy, the tumour nevertheless it probably requires years of exposure to provoke the must be eradicated. Various treatments can be used including incipient lesions of actinic cheilitis on the lower lip (11). excision pattern, Mohs micrographic surgery, radiation therapy, UV exposure causes dysplastic changes at the cellular level, , and EDC. Mohs micrographic surgery is more which results in the formation of keratin (2). Actinic cheilitis presents effective in preventing local recurrence of carcinoma of the with projections, lips covered with cracks and ulcerations (13). It lips, gives a better cosmetic result, but is readily available only in is usually an isolated lesion, but multiple lesions may occur. The centres of greater importance. All other treatments have roughly initial lesion induced by the sun is grey or brown, and the vermilion the same cure rate (2). Squamous cell carcinoma of the lips has of the lips becomes indistinguishable and shows generalized the best prognosis of all oral forms of this kind. Labral lesions can atrophy. A common complaint of patients is the dryness of be detected early and removed at rates free of recurrenceof90% the lips and the rays reach over the lower lip due to the angle at 5 years (2). of incidence. The reason for the susceptibility of changes in Worldwide, more than 300 000 cases of squamous cell carcinoma actinic lips are numerous and include lack of coating keratin, are diagnosed each year, which represents approximately 90% epithelial thin, a lower amount of melanin, decreased sweat, of . Squamous cell carcinoma is associated with high and oil glands (2). rates of morbidity and mortality due to advanced clinical stage at which it is diagnosed (18, 19). In Brazil, cancer ofthemouth plays an important role in epidemiological indices, however the statistics available are those used for cancer of the mouth, since there are no data showing isolated incidence. Lip cancer represents 25% to 30% of all mouth cancer diagnoses .Squamous cell carcinoma is the most common histological type, accounting for 95% of cases. When diagnosed at an early stage, it has a cure rate of 80 to 90% and a mortality rate between 10 and 15%. When metastases occur in late stage, mortality reaches 11 to 18%, meaning that the 5-year survival drops to 25% (5).

OBJECTIVE

The purpose of this paper is to provide a review of the relevant literature about the relation ofactinic cheilitis and the prevention of oral cancer. In this way, we will show the many kinds of treatment available to prevent malignant transformation. Figure 1. Clinical aspect of actinic cheilitis in the lower lip.

DISCUSSION Men have higher rates of actinic cheilitis than women, and it is The main cause of actinic cheilitis is prolonged exposure to believed that women are less affected due to the protective UV light (11). Although solar radiation is the most important risk barrier provided by the use of lipstick, which can partially protect factor for the development of ulcers, it is not the only one. Other the lip from sunlight, and because they generally engage in less factors are associated such as smoking, alcohol abuse, HPV, outdoor activity. Clinically, actinic cheilitis is dried, peeled and race, familial and genetic predisposition, immunosuppression, of varied colour on the lips. It may be associated with atrophy, swelling, , and ulceration. The vertical grooves may CONCLUSION become more pronounced and the greyish discoloration may become apparent (14). Cases of actinic cheilitis manifest with The range of options for the treatment of actinic cheilitisis various clinical appearance of leukoplakia and glandular cheilitis are and each alternative has advantages and disadvantages also observed. Actinic cheilitis tends to have a rough texture, (15), since each treatment exhibits collateral effects. Finally, the and palpation may be useful in defining and diagnosing lesions essential components include the careful monitoring routine (15). There is a loss of the format of the edge of the lip, red lip to monitor the recurrence of disease and emphasize the sun atrophy, and darkening at the boundary between the lip and protection habits (15). the face skin. As the lesion progresses, roughness and scaling It is important to diagnose and treat lip lesions, not only to prevent areas become thick. The focal chronic ulcers may occur in morbidity and mortality, but also to maintain self-esteem and more than one area (Figure 1). social acceptance of the patient. It takes months to years for the Despite the available means of prevention and early progression of squamous cell cancer in situ. Early diagnosis and clinical diagnosis being easy, many factors are attributed to cure are possible in most cases. problems in the clinical diagnosis of actinic cheilitis such as Lesions of the lip are usually present in doctors. These lesions are alack of knowledge of the injury, no pain, the initial clinical often benign and may only require aesthetic treatment. Recall appearance without damage to the epidermis, and the that women are less affected because the protective barrier lack of professional knowledge, which in many cases may exerted by the use of protective labial. However, a small number consider the injury as simply a chronic inflammatory process. of cases are potentially lethal and therefore require appropriate Since the occurrence of episodes are short and followed by intervention. Medical care includes observation, diagnosis, and remission of signs and symptoms, many patients associate treatment of various lip injuries (2.) There is no consensus as to the changes of the lips as a result of their occupation, as part the frequency with which actinic cheilitis becomes carcinoma. of the context of their occupational activities like calluses on Morphological analysis of this type of injury is subjective and is hands and skin tanning (5). not enough to confirm for sure which lesion will progress to oral A is recommended for cases where actinic cheilitis squamous cell carcinoma (2). has caused the loss of transition between the red lip and Finally, it is important to address the risk of progression of actinic normal skin, change in the texture of the lip palpation, and cheilitis for a squamous cell carcinoma that prevention is the the texture of semimucosa ulceration (5). The degree of best alternative. Therefore, the protection of the lips and skin histological damage and malignant potential cannot be to the sun by wearing a hat and umbrella, plus the use of lip observed clinically. Each case of injury should be investigated balms to ultraviolet rays is essential especially to Caucasians that and treated aggressively. Any suspicious lesion should undergo remain frequently exposed to the sun during work. Obviously, self- biopsy and examine microscopically, or be sent to a specialist. examination and attendance at preventive visits to professional Once the diagnosis is confirmed, many treatments are medical and dental facilities are of special interest and indication. available (2). Among the various treatments is cryo-surgery, which involves the application of liquid nitrogen to the treatment of multiple REFERENCES AND NOTES skin lesions. Actinic cheilitis has been successfully treated by cryosurgery, because of the smooth surface of the mucous 1. Carnelio S., Rodrigues G.S., Shenoy R., Fernandes D., Indian J membrane and moisture for quick freezing. (15). Surg. 2011; 73(4): 256-261. 2. Bentley J.M., Barankin B., Lauzon G.J., Can Fam Physician. 2003; This kind of treatment is relatively inexpensive and requires 49: 1111-1116. no special skill level as with vermilionectomy. Collateral 3. Picascia D.D., Robinson J.K., J Am Acad Dermatol. 1987; 17(2 Pt effects include postoperative , pain during and after 1): 255-264. treatment, migraine, neuropathy, and dischromia (16). 4. Greenberg M., Glick M., Medicina Oral de Burket. Diagnóstico e According to Shah, the application of trichloroacetic acid is Tratamento. 10 ed 2008. easy and convenient but less effective. Various formulations 5. Vieira R.A., Minicucci E.M., Marques M.E., Marques S.A., An Bras and concentrations are available, and such variability Dermatol. 2012; 87(1): 105-114. decreases the possibility of criticizing the evolution of published 6. Marks R., Rennie G., Selwood T.S., Lancet. 1988; 1(8589): 795-797. evidence. Most suggest one to two times per day for a period 7. Huber M.A., Clin Dermatol. 2010; 28(3): 262-268. of some weeks. Topic 5-FU has several side effects, including 8. Ron E., Radiat Res. 1998; 150 (5 Suppl): S30-S41. 9. Warnakulasuriya S., Johnson N.W., van der Waal I., J Oral Pathol edema and erythema of the lips, as well as induction of Med. 2007; 36(10): 575-580. erosion to the ulcer. These symptoms often persist throughout 10. Tommasi A.F., Diagnóstico em Patologia Bucal. 3 ed 2002. 600 p. the treatment. Temporary pain and cosmetic disfigurement 11. Schwartz R.A., Bridges T.M., Butani A.K., Ehrlich A., J Eur Acad are also expected. Furthermore, 5-FU acts as enhancing the Dermatol Venereol. 2008; 22(5): 606-615. photosensitizing symptoms with sun exposure. 12. Abreu M.A., Silva O.M., Neto Pimentel D.R., Hirata C.H., Weckx L.L., It is believed that the presence of actinic cheilitis increases to Alchorne M.M., et al., Braz J Otorhinolaryngol. 2006; 72(6): 767-771. more than twice the risk of squamous cell carcinoma. (17) In 13. Moy R.L., J Am Acad Dermatol. 2000; 42(1 Pt 2): 8-10. terms of current treatments, for aggressive treatment actinic 14. Cavalcante A.S., Anbinder A.L., Carvalho Y.R., J Oral Maxillofac cheilitis is preferred to avoid the development of invasive Surg. 2008; 66(3): 498-503. cancer, such as squamous lip associated with a high risk of 15. Shah A.Y., Doherty S.D., Rosen T., Int J Dermatol. 2010; 49(11): 1225-1234. metastasis (15). 16. Ishida C.E., Ramos-e-Silva M., Int J Dermatol. 1998; 37(4): 283-285. While not all oral carcinomas are preceded by precancerous 17. Dufresne R.G., Curlin M.U., Dermatol Surg. 1997; 23(1): 15-21. lesions clinically visible, changes occur secondarily at the 18. Santos L.R., Cernea C.R., Kowalski L.P., Carneiro P.C., Soto M.N., cellular or molecular level and high-risk lesions should be Nishio S., et al., Sao Paulo Med J. 1996; 114(2): 1117-1126. identified. Surgical excision is still controversial to prevent 19. Zitsch R.P., Park C.W., Renner G.J., Rea J.L., Otolaryngol Head malignant medical and as a conservative technique (1). Neck Surg. 1995; 113(5): 589-596.

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