Photo Quiz: Can You Identify These Oral and Perioral Lesions?

Case 1:

For 8 months, a 44-year-old man hashad a 2-mm superficial ulcer on histongue. The lesion is surrounded bya thin white rim and an area of whitediscoloration. The patient believesthat the ulcer resulted from thescratching of the rough edge of atooth against his tongue.

What approach would you take?

Case 1:

Consultation with a dentist confirmed that thelesion was caused by irritation from a roughened rightupper central incisor, resulting in leukoplakia lingualiswith ulceration. The offending tooth was smoothed; theulcer and leukoplakia subsequently resolved.

Leukoplakia is a common, potentially malignant orallesion that is more frequently seen in men than in women.There are 4 types¹:

• Simple leukoplakia may be associated with repetitivetrauma, as in this patient.

• Atypical leukoplakia features dysplasia and thickening ofthe epithelium; often, keratinization is present.

• Stomatitis nicotina is associated with pipe smoking.

• Leukoedema is characterized by wrinkling of the affectedarea, which may also appear waterlogged from edema.

Unless leukoplakia is associated with tertiary syphilis,chronic irritation, smoking, or alcohol abuse, thecause is usually unknown. Treatment consists of removalof the inciting agent or, if the lesion is atypical, surgical excisionof the affected area.

REFERENCE:

1.

Ritchie AC, Boyd W.

Boyd's Textbook of Pathology.

9th ed. Philadelphia: Lea &Febiger; 1990:974-976.(Case and photograph courtesy of Robert P. Blereau, MD.)

Case 2:

Brownish black discoloration recentlydeveloped on the tongue of a 6-yearoldboy who is being treated for sinusitis.White follicles on the tongueand lingual tonsil are also noted duringthe examination. The mother reportsthat her son had been vomitingthe night before.

What do you suspect?

Case 2:

The symptoms were attributed to amoxicillin/clavulanate, which the child had been taking for sinusitisdiagnosed 3 days earlier. The antibiotic was discontinued;oral promethazine and clear liquids were given. The patientrecovered completely within several days, and thetongue lesions resolved.

Black tongue (hairy tongue, or lingua nigra) is associatedwith the use of broad-spectrum antibiotics, radiationtreatment of the head and neck, and poor oral hygiene. It isseen more frequently in immunosuppressed patients and inusers of illicit drugs, alcohol, and tobacco.¹

The disorder is characterized by hypertrophy andelongation of the filiform papillae of the dorsal tongue withlack of normal desquamation. The papillae appear as hairsand may be yellow, white, brown, or--more frequently--black; the hue is determined by the source of the stain,which may be food, tobacco, medication, or pigment-producingbacteria.

Although the tongue's appearance can be a concern,the condition is rarely symptomatic. Taste disturbanceand halitosis may be present; gagging can occur if the filiformpapillae are particularly long and touch the palate.

Recovery is usually spontaneous after the culpritagent is removed. Gentle tongue brushing and proper oralhygiene can hasten resolution.

REFERENCE:

1.

Eisen D, Lynch DP.

The Mouth: Diagnosis and Treatment.

St Louis: Mosby;1998:20.(Case and photograph courtesy of Robert P. Blereau, MD.)

Case 3:

The crease adjacent to the mouth ofthis 88-year-old man has become irritatedand inflamed.

To what would you attributethese symptoms?

Case 3:

The natural crease at the corner of this man's mouth facilitated the developmentof angular stomatitis, or perlche. Saliva from the patient's mouthchanneled into the intertriginous space. The constant moisture caused maceration,chronic irritation, and fissures in the skin. A bacterial or yeast infectionperpetuates the condition.

Treatment of acute perlche includes 1 bedtime and 1 daytime applicationof an imidazole cream and of a mild topical corticosteroid, such as a 1% hydrocortisoneointment. When the condition is controlled, petroleum jelly can beapplied every night at bedtime to prevent recurrences.

(Case and photograph courtesy of Joe Monroe, PA-C.)

Case 4:

A 45-year-old man cannot recall howlong the slightly raised white patcheson his oral mucosa have beenpresent. Fluconazole prescribed byanother practitioner has failed toclear the lesions. The patient's medicalhistory is noncontributory; hetakes no medications.

White, lacy 4-cm plaques arenoted over the anterior buccal mucosabilaterally. No ulcerations are present.He has no other mucosal or cutaneouslesions.

What would you include in thedifferential, and how would you confirmthe diagnosis?

Case 4:

The differential diagnosis included oral mucosa lichen planus, leukoplakia,and candidal infection. Oral lichen planus was confirmed by a scoopbiopsy.

Oral lichen planus is an inflammatory reaction of unclear origin. The diseasecan occur without cutaneous involvement; however, more than 50% of patientswith cutaneous manifestations have mucous membrane lesions. ¹

The classic, white lacy network pattern with plaques or papules most oftenoccurs on the buccal mucosa; lesions also may be present on the tongue or lips.An erosive form of lichen planus that features painful local or extensive ulcerationsmay arise anywhere in the oral mucosa.

Lichen planus affects twice as many women as men; typically, patients areolder than 40 years. The skin lesions clear spontaneously without treatmentwithin 1 year in about 70% of affected persons; however, mucous disease recursin nearly 50% and may become chronic. ²

Treatment options include topical, oral, or injectable immunomodulatorsor corticosteroids. This patient was treated successfully with tacrolimus ointment,0.1% bid for 6 weeks.

REFERENCES:

1.

Habif TP. Clinical Dermatology:

A Color Guide to Diagnosis and Therapy.

4th ed. Philadelphia: Mosby; 2004:250-256.

2.

Odom RB, James WD, Berger TG.

Andrews' Diseases of the Skin: Clinical Dermatology.

9th ed. Philadelphia: WB Saunders Co; 2000:266-274.
(Case and photograph courtesy of Jonathan S. Crane, DO; Patricia B. Hood, PA-C; and John Schoonmaker, PA-C.)

Case 5:

For several months, a 26-year-old woman has had papules and erythemaaround her mouth that she self-treated with her husband's topical clobetasol.The initially minor eruption has persisted and worsened.

What is responsible for this rash?

Case 5:

The rash was diagnosed as steroid-exacerbatedperioral dermatitis. Acne vulgaris, rosacea, and tineafacei were also considered in the differential. Acne wasunlikely because of the absence of comedones and pustules;rosacea specifically spares the area affected in thispatient; and tinea facei was ruled out by a potassium hydroxideevaluation.

The culprit corticosteroid was immediately discontinued;oral tetracycline, given for 2 months, resolved thedermatitis.

Widespread application of a topical corticosteroid todermatitis on the face can lead to a more extensive rash;the periocular areas are especially susceptible. Cautionyour patients to avoid the use of high-potency corticosteroidson the face unless the preparation is specificallyprescribed.

(Case and photograph courtesy of Joe Monroe, PA-C.)