Labial Lesion with Heterogeneous Aspects in a Patient with Chronic Renal Failure: Diagnostic Difficulties and Literature Review ^†

1. Introduction

Lips are a complex anatomical structure with a significant functional and aesthetic role which can be affect by numerous pathologies with different etiology [1]. Furthermore, lips often reveal to be the first site of manifestation of important systemic diseases [2]. This emphasizes the role of the dentist in the early detection of these disorders.

2. Purpose

Aims of this work are to describe an unusual case of adverse labial solar reaction and to make a brief review of the literature of pathologies included in the differential diagnosis.

3. Case Report

A 78-year-old woman patient was visited, in February 2019, for the sudden appearance of a lesion on the lower lip. Her medical history showed: chronic renal failure (CRF) and consequent cardiovascular disease. The patient underwent hemodialysis three times a week and her medications consisted of: furosemide, calcium carbonate, calcitriol and sodium polystyrene sulfonate for the CRF treatment and amlodipine, carvedilol, telmisartan and low molecular weight heparin for the cardiovascular disease treatment. Upon clinical examination, an irregular lesion was found localized on the entire surface of the lower lip characterized by active bullous lesions and completely eroded areas, partially ulcerated covered by clots and fibrin (Figure 1a). Further evaluation did not reveal other lesions in the upper lip, buccal mucosa, perioral and general skin. The patient reported a sun exposure shortly before the lesion appeared. Clinical features initially suggested a malignant or premalignant disease for which an incisional biopsy was planned that was no longer performed following the brief healing of the lesion occurred in five days (Figure 1b). The patient reported having used, as an emergency treatment, the mucilaginous gel from the parenchymatous leaves of Aloe vera, with subsequent immediate relief.

4. Literature Review

A search of the National Library of Medicine’s PubMed Database was conducted using the word “lip” together with one or more of the following key words: “cancer”, “actinic cheilitis”, “erythema multiforme”, “burn”, “bullous infection”, “pemphigoid” and “pemphigus” in the last ten years. Inclusion criteria were any labial disease included in the differential diagnosis: malignant and premalignant pathologies, vesiculobullous, ulcerative and infectious diseases, adverse drug reactions and chemical burns. The initial search strategy yielded 2197 potentially relevant publications, of these, 636 studies were included in the review.

5. Result and Conclusions

The review did not lead to any clinical case similar to the one examined, which presents a very complex diagnostic decision-making approach. In literature, however, numerous cases of crusted vesiculobullous photodermatoses have been attributed to cases of pseudoporphyria (PP) [3]. Development of PP has been associated with sun exposure, CRF, hemodialysis and medications including diuretics and unlike porphrya cutanea tarda, hypertrichosis and sclerodermoid changes are not seen in PP, all factors present in this case.