What is the appropriate evaluation and management for a papular lesion on the lower lip?

Evaluation and Management of a Papular Lesion on the Lower Lip

Any papular lesion on the lower lip requires excisional biopsy for definitive diagnosis, as clinical examination alone cannot reliably distinguish benign from premalignant or malignant lesions.

Initial Clinical Assessment

Key Physical Examination Features

Examine for malignancy indicators including asymmetry, irregular borders, color variation, diameter >6mm, ulceration, induration, or fixation to underlying structures, as these strongly suggest melanoma or squamous cell carcinoma 1.

• Palpate the lesion to assess depth, texture, and mobility, as fixation indicates possible deeper invasion 1
• Inspect the entire lip surface including vermilion border, mucosal surface, and surrounding skin for satellite lesions or ulceration 1
• Examine cervical, submandibular, and submental lymph nodes, as non-tender masses are more suspicious for malignancy 1
• Perform complete oral cavity examination with dentures removed, inspecting floor of mouth, lateral tongue, oropharynx, and tonsils for synchronous lesions 1
• Assess tongue mobility, as limitation may indicate muscle or nerve invasion 1

Risk Stratification

Patient age >40 years significantly increases suspicion for squamous cell carcinoma 1. Document tobacco and alcohol use, as these are present in 75% of oral cancers 1. Chronic sun exposure is the primary risk factor for actinic cheilitis and lip SCC, with the lower lip being most commonly affected (56-66% of cases) 2, 3, 4.

Differential Diagnosis by Lesion Type

Benign Papular Lesions

The most common benign papular lesions include:

• Squamous papilloma (pedunculated or sessile with papillary projections, pink or white depending on keratinization, caused by HPV 6/11 in ~50% of cases) 2, 5
• Verruca vulgaris (white pebbly or papillary surface with heavy granular layer and koilocytes, caused by HPV 2/4 via autoinoculation) 2, 5
• Condyloma acuminatum (sessile or pedunculated with papillary projections, sexually transmitted, caused by HPV 6/11 but may harbor high-risk HPV 16/18) 2, 5
• Hemangioma (most common benign lesion at 19.28% in one series) 3
• Fibroma (9.28% of benign lip lesions) 3

Premalignant Lesions

Actinic cheilitis represents a potentially malignant disorder requiring close surveillance 6. Clinical features associated with higher-grade dysplasia include:

• Erosion, ulceration, and crusts (significantly associated with moderate/severe dysplasia and high malignancy risk) 6
• Blurring between lip border and skin (associated with lower-grade dysplasia) 6
• Clinical index scores ≥10-11 indicate need for biopsy 6

Malignant Lesions

Squamous cell carcinoma is the most common malignant lip lesion 3, 4. The lower lip is affected in approximately 65-66% of all lip lesions 4.

Diagnostic Approach

Excisional biopsy is the recommended treatment for all papular lesions, as it provides both diagnosis and definitive treatment 2. This is critical because:

• Clinical and pathological distinction between squamous papilloma, condyloma acuminatum, and verruca vulgaris is often difficult 2
• Only a small percentage of oral papillomas and condylomata can be dysplastic, particularly those harboring high-risk HPV genotypes 2
• Malignant transformation has not been reported in verrucae but can occur in condylomata with high-risk HPV 2

Biopsy Technique Based on Location

For lesions located exclusively on the vermilion: Use a transverse mucosal incision at the vermilion-vestibular junction to hide the scar 1, 7.

For lesions crossing the vermilion-cutaneous border: Use a vertical incision or wedge excision 1, 7.

For bulkier lesions causing lip lengthening: Wedge excision is preferred 7.

Treatment by Diagnosis

HPV-Related Benign Lesions

Surgical excision is the definitive treatment for oral verruca vulgaris, squamous papilloma, and condyloma acuminatum 2. Recurrence is unusual and typically results from incomplete removal of infected epithelium at the lesion base 2.

Actinic Cheilitis

Treatment options include:

• Simple excision with primary closure for localized lesions 1
• CO2 laser ablation for premalignant lesions, though this may cause more scarring 1
• Photodynamic therapy (ALA-PDT) for extensive lesions where surgery would cause significant disfigurement 1

Squamous Cell Carcinoma

Radiotherapy offers comparable cure rates to surgery and often provides the best cosmetic and functional results for lip lesions 2. Surgical excision by experienced surgeons is also appropriate 2.

Elective prophylactic lymph node dissection has been proposed for lip SCC >6mm depth, but evidence is weak and this is not routinely practiced 2.

Patients with high-risk SCC or clinically involved lymph nodes should be reviewed by a multiprofessional oncology team including dermatologist, pathologist, trained surgeon (plastic or maxillofacial), clinical oncologist, and oncology nurses 2.

Post-Biopsy Care

• Apply white soft paraffin or petroleum-based ointment every 2 hours to prevent drying and cracking 1
• Avoid irritants including spicy foods, hot beverages, and citrus fruits 1, 7
• Maintain oral hygiene with soft toothbrush and mild fluoride toothpaste 1, 7
• Perform warm saline rinses daily 1

Follow-Up

For high-risk SCC, observation for 5 years is reasonable, as 95% of local recurrences and metastases are detected within this timeframe 2. Patients should be instructed in self-examination 2.

For benign lesions, follow-up ranges from 6 months to 2 years, with recurrence being rare (single case in one series of 116 benign lesions) 3.