To which specialist should a patient with a non‑healing lip lesion be referred for assessment and possible biopsy?

Referral for Non-Healing Lip Lesion

A patient with a non-healing lip lesion should be urgently referred to an oral and maxillofacial surgeon, head and neck surgeon, or dermatologist with expertise in oral mucosal lesions for biopsy and definitive diagnosis, as any persistent ulcer or non-healing lesion on the lip must be biopsied to exclude squamous cell carcinoma. 1, 2

Urgency and Rationale

• Any non-healing ulcer, persistent erosion, or chronic lesion of the lip requires tissue biopsy to exclude malignancy, particularly squamous cell carcinoma (SCC), which is the most common malignancy at this site 3, 1
• Lip SCC exhibits intermediate aggressiveness between cutaneous SCC and oral mucosal SCC, with higher rates of nodal metastasis (approximately 10-15%) and worse outcomes than typical skin cancers 2
• Chronic ulcers or exophytic lesions are classic signs of lip carcinoma, especially in patients over 50 years with sun exposure history 4

Appropriate Specialists

The following specialists are appropriate for referral, listed in order of preference based on the clinical context:

• Oral and maxillofacial surgeon: Primary choice for lip lesions, as they manage the interface between cutaneous and mucosal structures 2
• Head and neck surgeon (otolaryngologist): Appropriate for suspected malignancy requiring comprehensive staging and potential lymph node assessment 3, 2
• Dermatologist with oral mucosal expertise: Suitable for lesions suspected to be actinic cheilitis or other premalignant conditions 3, 4

Critical Clinical Features Requiring Urgent Referral

Document and communicate these high-risk features to the specialist:

• Duration of non-healing (lesions present >2-3 weeks warrant biopsy) 1
• Infiltration or blurring of the vermilion border (strongly associated with dysplasia and malignancy) 5
• Persistent ulceration, erosion, hyperkeratosis, or erythematous zones (must be biopsied to exclude intraepithelial neoplasia or invasive SCC) 3
• Any new growth or change in existing lesion 3
• Patient risk factors: chronic sun exposure, fair skin, age >50, tobacco/alcohol use, immunosuppression 1, 2, 4

Diagnostic Approach by Specialist

• Full-thickness excisional biopsy is preferred over punch biopsy when feasible, including the entire lesion with 2-5mm margins of normal tissue to allow complete histopathologic assessment 3, 6
• Core needle biopsy or incisional biopsy may be performed for larger lesions where complete excision would cause significant functional or cosmetic morbidity 3
• The specimen must be sent for histopathologic examination to confirm diagnosis, assess depth of invasion (Breslow thickness), presence of perineural invasion, and margin status 3, 6

Common Pitfalls to Avoid

• Never treat empirically with antibiotics or topical steroids without first obtaining tissue diagnosis, as this delays diagnosis of malignancy 3
• Do not perform cytology alone (such as exfoliative cytology), as it is not useful for detecting epithelial dysplasia or malignant alterations in lip lesions 5
• Avoid laser or electrocoagulation for removal, as tissue destruction interferes with histologic diagnosis 7
• Do not assume benign appearance excludes malignancy—actinic cheilitis and early SCC can appear as subtle white/red changes 4, 5

Follow-Up Coordination

• If malignancy is confirmed, the patient requires staging evaluation including examination of regional lymph nodes (submandibular, cervical) and potentially imaging (CT or MRI) for advanced lesions 3, 2
• Patients with premalignant lesions (actinic cheilitis, epithelial dysplasia) require long-term surveillance every 3-6 months initially, then annually 3
• Patient education about sun protection, smoking cessation, and self-examination for new or changing lesions is essential 3, 4