What is the best evidence-based treatment for lightening and improving the appearance of smoker's lips in a patient with a history of smoking?

Treatment for Lightening Smoker's Lips

The most effective evidence-based approach for lightening smoker's lips is smoking cessation combined with autologous platelet concentrates (APCs), specifically PRP injections, which have demonstrated the most obvious improvement in lip color vibrancy. 1

Primary Intervention: Smoking Cessation

Smoking cessation is the foundational treatment that must be addressed first, as continued tobacco exposure perpetuates the discoloration and undermines any cosmetic intervention. 1

Recommended Cessation Protocol

• Combination nicotine replacement therapy (21 mg patch plus short-acting NRT) or varenicline (2 mg/day) as first-line pharmacotherapy 2
• Minimum 4 behavioral counseling sessions (10-30+ minutes each) during the 12-week pharmacotherapy course 2
• Varenicline shows the highest 6-month abstinence rate at 33.2%, while combination NRT achieves 36.5% 2
• Follow-up within 2 weeks of starting therapy and at 12-week intervals thereafter 2

Clinical Rationale for Cessation Priority

The yellow-brown discoloration of smoker's lips results from direct tobacco tar and nicotine deposition on the vermillion border and perioral skin. 3, 4 This discoloration originates centrally over the philtrum and expands laterally, often accompanied by similar discoloration of fingernails (nicotine sign). 3, 4 Without cessation, any lightening treatment will be temporary and continuously undermined by ongoing tobacco exposure. 4

Secondary Intervention: Autologous Platelet Concentrates (PRP)

Once smoking cessation is initiated or achieved, PRP injections provide the strongest evidence for improving lip color and appearance. 1

PRP Administration Protocol

• Use 27-30 gauge needles or 25 gauge cannula 1, 5
• Inject 0.2-0.5 mL per quadrant in a retrograde fashion 1, 5
• Position injections above the orbicularis oris muscle to avoid vascular complications 1, 5
• Three monthly treatment sessions are required, with maintenance every 6 months 1

Evidence for PRP in Lip Color Improvement

The 2025 Periodontology 2000 guidelines specifically note that "the most obvious improvement was that the color of the lips which became more vivid" when using PRP for lip rejuvenation. 1 This represents the highest quality evidence directly addressing lip color lightening. Additional benefits include:

• Improved moisture and dermal structure 1
• Biostimulation with natural collagen production 1
• Restoration of dermal matrix 1
• High patient satisfaction scores (4.4/5) with clinician satisfaction of 4.33/5 1

Important Limitations of PRP

PRP provides rejuvenation and color improvement but limited volumizing effects beyond 3 months. 1, 5 The 3D volumizing effect does not persist, though rejuvenation benefits continue. 1 This is acceptable for smoker's lip treatment where color correction, not volume, is the primary goal.

Adjunctive Topical Considerations

While the evidence provided focuses primarily on smoking cessation and PRP, topical PRP applied at home for 12 weeks has shown improvement in moisture, collagen fibers, and skin elasticity in the perioral area. 1 This may serve as a maintenance strategy between injection sessions.

Combination Approach with Fractional CO2

One study demonstrated that fractional CO2 resurfacing plus intradermal PRP improved multiple parameters in the perioral area. 1 However, this combination requires further validation and should be considered only after establishing the baseline response to PRP alone.

Common Pitfalls to Avoid

• Do not attempt cosmetic lightening interventions without addressing smoking cessation first - the discoloration will recur with continued tobacco exposure 3, 4
• Avoid superficial injection depths - maintain positioning above the orbicularis oris muscle to prevent vascular injury 1, 5
• Do not provide pharmacotherapy for smoking cessation without behavioral counseling - combination therapy is significantly more effective than either alone 2
• Avoid expecting significant volumizing from PRP - set realistic expectations that PRP provides color and texture improvement, not lasting volume enhancement 1, 5
• Do not dismiss mild discomfort during PRP injections - three participants in studies experienced mild pain, but no serious complications occurred 1

Treatment Algorithm

1. Initiate smoking cessation with combination NRT or varenicline plus behavioral counseling 2
2. After 2-4 weeks of cessation (or in highly motivated patients concurrently), begin PRP injection series 1
3. Administer 3 monthly PRP sessions using proper technique (27-30G needle, 0.2-0.5 mL per quadrant, above orbicularis oris) 1, 5
4. Assess response at 3 months post-final injection 1
5. Maintain with PRP every 6 months and continued smoking abstinence 1
6. Consider topical PRP for home maintenance between injection sessions 1

Safety Profile

PRP for lip treatment is safe with minimal adverse events. 1 The most common side effects are mild pain during injection, with no reports of swelling, bruising, or scar hyperplasia in the primary studies. 1 Smoking cessation pharmacotherapy is also safe, with blood nicotine levels from NRT significantly lower than from smoking, making toxicity rare even with concurrent smoking. 2