Atypical Cheilitis

The patient is a 58 yo gynecologist who has had a scaly lower lip for over seven months. When it began, she was wearing orthodontic braces. These were removed around four months ago, but the scaling on the lower lip has persisted. She is a non-smoker. She has treated patients with genital warts with a laser for years and had questions about virus in the plume.

O/E: Hyperkeratosis of lateral portions of the lower lip. This is not the picture of leukoplakia usually seen with lichen planus or actinic cheilitis.




She was treated with hydrocortisone valerate 0.2% cream which was marginally helpful and then clobetasol ointment which was not effective.

Please tell me your thoughts. I am planning a biopsy. Most likely a 3 mm punch -- would you punch or shave?

Thank you.