Contents

Search

leukoplakia; leukokeratosis; leukoplasia

Formation of white patches on the mucous membrane of the tongue, cheek, lip or other mucosal surface (vagina, cervix) Etiology: 1) smoking (cigar, pipe, cigarette) 2) smokeless tobacco 3) alcohol 4) human papilloma virus (HPV-16, HPV-18) 5) syphilis (tongue) 6) chewing of betel nuts [13] 7) irritation from denture or jagged tooth Epidemiology: - proliferative verrucous leukoplakia 4-fold more common in women than men [3] - mean age of diagnosis = 60 years Pathology: 1) dysplasia of keratinocytes 2) keratinization of single cells 3) abnormal mitoses 4) increased nuclear/cytoplasmic ratio 5) nuclear pleomorphism 6) prominent nucleoli 7) precancerous lesion [4] 8) verrucous leukoplakia is a multifocal, progressive, & aggressive form of oral leukoplakia Clinical manifestations: 1) lesions are smooth, irregular in size & shape, hard & occasionally fissured 2) they are not easily scraped off 3) small or large plaque; homogeneous or speckled pattern 4) ulceration may be present 5) color: gray-white, red areas (erythroplakia) 6) moderately rough or leathery in texture 7) 2-4 cm plaque often angular in shape 8) distribution: buccal mucosa, retrocommissural mucosa, tongue, hard palate, sublingual region, gingiva, vagina 9) speckled white papules on an atrophic red background generally indicated malignant transformation 10) duration of lesions: years 11) generally asymptomatic * images [8,10,11,12,13] Laboratory: - punch biopsy red regions (erythroplakia) within the white plaque as these are indicators of dysplasia Differential diagnosis: 1) lichen planus - occurs in older persons, associated with chronic trauma or medications - lesions variable: reticular white plaques of the oral mucosa - erosions & ulcerations may be painful 2) oral lesion of lupus erythematosus 3) oral hairy leukoplakia - adherent white plaques, associated with EBV, HIV1 infection 4) condyloma acuminata 5) bite 'callus' 6) leukoderma 7) nicotine stomatitis 8) thrush: non-adherent white plaques or pseudomembranes 9) geographic tongue - appearance of denuded red patches migrating across the surface of the tongue - map-like erythematous patches with white hyperkeratotic rims on dorsal surface of tongue [16] Complications: 1) secondary infection with Candida 2) squamous cell carcinoma 3) proliferative verrucous leukoplakia has a high rate of - recurrence after ablation or surgical excision [3] - malignant transformation (4-12 years) Management: 1) about 10% of lesions transform into squamous cell carcinoma a) leukoplakia of the buccal mucosa is generally benign b) leukoplakia in the floor of the mouth is worrisome - 60% show carcinoma in situ or invasive squamous cell carcinoma 2) biopsy of lesions 3) cryotherapy of dysplastic lesions with liquid nitrogen 4) oral beta-carotene may be of some benefit 5) surgical excision of carcinoma in situ or invasive squamous cell carcinoma 6) total surgical excision generally not feasible in multifocal form 7) laser ablation of hypertrophic verrucous leukoplakia [3,13] 8) 13-cis-retinoic acid (topical or systemic) may benefit 1/3 of patients (investigational) [7]

Related

erythroplakia leukoderma (hypomelanosis)

Specific

hairy leukoplakia keratosis nicotina palatini (nicotine leukoplakia)

General

abnormal morphologic structure (malformation)

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 968-69
  2. Color Atlas & Synopsis of Clinical Dermatology, Common & Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY, 1997, pg 208-210
  3. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  4. Medical Knowledge Self Assessment Program (MKSAP) 15, 17 American College of Physicians, Philadelphia 2009, 2015
  5. Bagan JV, Jimenez-Soriano Y, Diaz-Fernandez JM et al Malignant transformation of proliferative verrucous leukoplakia to oral squamous cell carcinoma: a series of 55 cases. Oral Oncol. 2011 Aug;47(8):732-5. Epub 2011 Jun 16. PMID: 21683646
  6. Gandolfo S, Castellani R, Pentenero M. Proliferative verrucous leukoplakia: a potentially malignant disorder involving periodontal sites. J Periodontol. 2009 Feb;80(2):274-81. PMID: 19186968
  7. Poveda-Roda R, Bagan JV, Jimenez-Soriano Y et al Retinoids and proliferative verrucous leukoplakia (PVL). A preliminary study. Med Oral Patol Oral Cir Bucal. 2010 Jan 1;15(1):e3-9. PMID: 19680182
  8. Wikipedia: Leukoplakia (image) http://en.wikipedia.org/wiki/Leukoplakia
  9. Harris CM, Meyers AD Medscape: Oral Leukoplakia http://emedicine.medscape.com/article/853864-overview
  10. Scully C, James WD (images) Medscape: Dermatologic Manifestations of Oral Leukoplakia http://emedicine.medscape.com/article/1075448-overview
  11. Bishop JA, Anton R (images) Medscape: Leukoplakia and Erythroplakia - Premalignant Squamous Lesions of the Oral Cavity. http://emedicine.medscape.com/article/1840467-overview
  12. DermNet NZ. Oral leukoplakia (images) http://www.dermnetnz.org/site-age-specific/oral-leukoplakia.html
  13. Chakrabarti D, Akhtar N. Images in Clinical Medicine White Plaque on the Tongue. N Engl J Med 2021; 384:e75. May 20 PMID: 34010533 https://www.nejm.org/doi/full/10.1056/NEJMicm2032955
  14. Torrejon-Moya A, Jane-Salas E, Lopez-Lopez J. Clinical manifestations of oral proliferative verrucous leukoplakia: a systematic review. J Oral Pathol Med. 2020;49:404-408 PMID: 31990082 https://onlinelibrary.wiley.com/doi/10.1111/jop.12999
  15. Warnakulasuriya S. Oral potentially malignant disorder: a comprehensive review on clinical aspects and management. Oral Oncol. 2020;102:104550. PMID: 31981993 https://www.sciencedirect.com/science/article/abs/pii/S1368837519304609
  16. NEJM Knowledge+