Lower lip verrucous lesion unmasking squamous cell carcinoma: A diagnostic pitfall

Squamous cell carcinoma (SCC) is one of the most common malignant neoplasms affecting the skin and oral mucosa.
A 79-year-old man with a history of prostate adenocarcinoma presented with a verrucous lesion of the lower lip that had been evolving for six months. The patient reported repeated use of traditional remedies. He was a former smoker and had a history of chronic sun exposure. Dermatological examination revealed a verrucous plaque with a crusted surface and a papillomatous hyperkeratotic appearance located on the lower lip. 
Dermoscopic examination showed white structureless areas, polymorphous vessels, and hemorrhagic foci, supporting the suspicion of a keratinizing epithelial neoplasm and prompting immediate biopsy. Histopathological examination of the initial biopsy suggested verrucous carcinoma (VC) without definite stromal invasion. However, comprehensive examination of the surgical specimen revealed a well-differentiated infiltrating squamous cell carcinoma (pT2N0M0).
The patient underwent complete surgical excision followed by reconstructive surgery and remained free of local recurrence during three years of follow-up. This case underscores the diagnostic challenge of verrucous lip lesions and highlights the complementary role of dermoscopy in guiding early biopsy. It also illustrates the limitations of incisional biopsy in verruciform lesions, as the invasive component was identified only after examination of the entire resection specimen.