Letters to the Editor

Recognition and Treatment of Actinic Cheilitis

TO THE EDITOR: The article in American Family Physician is a comprehensive review of the available therapeutic options for patients with actinic keratoses. Although the article illustrates useful recommendations for actinic keratoses, we would like to make some clarifications and suggest further treatments.

Actinic cheilitis is a clinical variant of actinic keratoses developing typically on the lower lip (the more sun-exposed area), which has a greater risk of progression to invasive squamous cell carcinoma compared with normal skin.1 Early actinic, keratotic lesions of the lips may have a rough contour and/or appear slightly white (milky discoloration). More advanced lesions appear erythematous, thickened, and may show fissuring, scaliness, or ulcerations (Figure 1A) with loss of the vermilion border.1 Any suspicious thickened, ulcerated, or cryotherapy-resistant lesions should be biopsied first; we advise using the shave technique to avoid scarring.2

Figure 1A. Typical eroded lesion of actinic cheilitis at the lower lip with evident fissuring inflammation and mild scaliness.

Figure 1B. Cryotherapy treatment of a single lesion of actinic cheilitis.

Treatment options for actinic cheilitis include emollients, electrosurgery, cryotherapy (Figure 1B), 5-fluorouracil, photodynamic therapy, curettage, excision, lasers, and occasionally, radiotherapy. The use of a prophylactic sunscreen containing lip pomade slows the rate of development of solar lesions and protects the skin from further damage.2 Carbon dioxide laser treatment of actinic cheilitis is a highly effective option for extensive lesions and usually results in minimal recurrence with excellent cosmetic results.3

Topical 5-fluorouracil is preferable for patients with multiple thin lesions, for whom the use of cryotherapy or other more aggressive treatments would cause unwanted
aesthetic results.4 Photodynamic therapy using 5-aminolevulinic acid5 can lead to satisfactory outcomes. Other options include topical therapy with diclofenac 3% gel (Solaraze) or imiquimod 5% (Aldara). The optimal dose and duration of topical therapies, as well as their long-term effectiveness, need to be established in large prospective studies.

George Larios, MD, MSc

E-mail: lariosgeo@gmail.com

Alevizos Alevizos, MD

E-mail: alevisos@gmail.com

Dimitris Rigopoulos, MD, PhD

E-mail: drigop@hol.gr

Athens, Greece

Author disclosure: Nothing to disclose.

Figures 1A and 1B are courtesy of Dr. Antonios Panagiotopoulos, MD.

REFERENCES

1. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. St. Louis, Mo.: Mosby, Inc; 2004:738.

2. James WD, Berger TG, Elston DM. Andrew's Diseases of the Skin Clinical Dermatology, 10th ed. Philadelphia, Pa.: W.B. Saunders Co; 2006:796.

3. Dufresne RG Jr, Curlin MU. Actinic cheilitis. A treatment review. Dermatol Surg. 1997;23(1):15-21.

4. White GM, Cox NH, eds. Diseases of the Skin: A Colour Atlas and Text. 1st ed. London: Mosby, 2000:291.

5. Kodama M, Watanabe D, Akita Y, Tamada Y, Matsumoto Y. Photodynamic therapy for the treatment of actinic cheilitis. Photodermatol Photoimmunol Photomed. 2007;23(5):209-10.

Corrections

The Practice Guideline Brief article "AAP Releases Guidelines on Treatment of Anaphylaxis," (October 15, 2007, page 1230) contained an error in the dosage for epinephrine injection for children with anaphylaxis. The dosage was incorrectly listed as "0.01 mg per kg, but no more than 0.30 mg per kg", but should have been "0.01 mg per kg, but no more than 0.30 mg." The article has been corrected online.

The article "Ulcerative Colitis: Diagnosis and Treatment," (November 1, 2007, page 1323) contained an error in Figure 1 on page 1327. In the far left branch of this algorithm, an arrow was inadvertently inserted from "Rectal 5-ASA maintenance" to "Oral steroids." The corrected algorithm is reprinted here and has been corrected online.

Send letters to Kenny Lin, MD, Assistant Editor, American Family Physician, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

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