A total of 15 images were thought to be necessary for the final
scale. Panel evaluations occurred in 2 phases. During evaluation
1, the images were rated independently based on the proposed
rating scale (Table 2) by each of the 3 experts. The ordinal scores
for each characteristic were summed to arrive at an overall lip
health score for each image. During evaluation 2, the images
with the greatest rater agreement (ie, ≥75% of experts agreed
on the image rating) during evaluation 1 were redistributed to
the expert panel for selection of the final images and verification
of the final scale. This evaluation session was repeated until 15
images (ie, 5 for each of the key characteristics and 1 for each ordinal
rating within a characteristic) were obtained. All 15 images
included in the final photonumeric scale (Figure 1) achieved
100% agreement among the raters.
DISCUSSION
This dermatologic study evaluated the lips of 103 subjects to
produce a photonumeric lip assessment scale that allows rating
of health issues associated with 3 key lip characteristics: shine,
texture, and vermilion border. The scale is designed for clinical
use to evaluate the efficacy of lip care products in achieving or
sustaining lip health. It comprises 15 images, 5 for each of the
key characteristics and 1 for each ordinal rating within a characteristic.
The study aimed to achieve ≥75% agreement among
the 3 expert panel members on all images selected for the final
photonumeric lip health scale. In fact, all 15 images included in
the final scale achieved 100% rater agreement.
Photonumeric scales are user-friendly, helpful skin assessment
tools.18 A 1992 study developed a photonumeric scale
for the evaluation of facial cutaneous photodamage. Those
researchers conducted a side-by-side comparison of their photonumeric
scale and a conventional, widely used descriptive
scale, also for assessing cutaneous photodamage.17 Use of a
photonumeric scale was found to be superior to use of purely
descriptive, written scales in the assessment of facial skin. Today,
numerous photonumeric scales for skin conditions have
been published.18,29-31
Extrinsic skin aging stemming from ultraviolet radiation, cigarette
smoking, air pollution, and other factors is both preventable
and treatable and can be distinguished from chronologic or intrinsic
aging.17,32 Three types of cheilitis that commonly occur
(ie, cheilitis simplex, angular/infective cheilitis, and contact/
eczematous cheilitis) are reversible with emollients and other
treatments.15 Nevertheless, and even though cheilitis may be associated
with numerous diseases (eg, diabetes, iron-deficiency
anemia), a clear classification system for cheilitis had not been
established as of 2018.15 Similarly, it appears that few studies
have investigated sun protection for the lips, despite the fact
that the lips are a high-risk location for squamous cell carcinoma.
In fact, the first European study of lip photoprotection
in patients with actinic cheilitis was published in 2019.33 As an anatomic structure central to many critical human functions, the
lips deserve more attention from dermatologists. Other treatable
lip conditions include dryness, chapping, and dull color,12
and unhealthy lips have a less distinct vermilion border, rough
texture, and reduced shine.12,27,28 Age- and sun-related changes
to the skin include wrinkles (increased quantity and visibility)17
and degeneration of elastic and collagen fibers,12 and the lips
also are a common site for eczematous dermatitis.15
Damage to the lip skin barrier is treatable by a variety of externally
applied substances, such as ceramides, hyaluronic acid,
licorice extracts, dimethicone, petrolatum, and paraffin wax.34
Moisturizers are important to basic skin care because they help
protect the skin by stimulating its natural barrier function, and
they respond to the skin’s continual need for moisture.35 Studies
support the use of lip creams in the winter, when conditions
are dry and cold.8 The application of lip balms, petroleum jelly,
emollients, and topical corticosteroids can help cheilitis simplex.
15
The present study has produced the only photonumeric rating
scale for assessing lip health. Technical expertise is required to
attain high-quality photographs for dermatologic rating purposes.
17 The VISIA-CR 4.3 system employed in the present study
uses digital technology to produce high-resolution images for
clinical research, which is a strength of this study.26 A limitation
of this research was the exclusion of subjects with Fitzpatrick
skin types IV–VI. In addition, this photonumeric scale was developed
for use only in Caucasian subjects. Future studies can
develop additional photonumeric lip health scales for other
populations with different skin types, as well as to validate the
present scale.
Despite these limitations, this scale provides healthcare professionals
a way to evaluate lip health, track improvement,
and establish the efficacy of lip care products. It can also serve
as a visual source of information that can be used during discussions
with patients about lip conditions and when making
treatment recommendations. In addition, the scale provides a
research tool to evaluate different formulations in the development
of lip products.
DISCLOSURES
Zoe Diana Draelos MD received an educational grant from Pfizer
to develop the lip health photonumeric scale. Darrell Rigel
MD received an educational grant from Pfizer to develop the
lip health photonumeric scale. Adam Friedman MD received an
educational grant from Pfizer to develop the lip health photonumeric
scale.
ACKNOWLEDGMENT
This study was sponsored by Pfizer Consumer Healthcare.
Medical writing support was provided by Dennis Stancavish of
