Oral Hairy Leukoplakia

July 2006

Chapter Contents

Background

Subjective

Objective

Assessment

Plan

Patient Education

References

Background

Oral hairy leukoplakia (OHL) is an oral infection caused by Epstein-Barr virus (EBV). It appears as white corrugated lesions (sometimes "hairy" in appearance) on the lateral aspects of the tongue. This infection may spread across the entire dorsal surface, onto the ventral surface of the tongue, and occasionally may be found on buccal mucosa. It is common in people with HIV infection, particularly in those with advanced immunosuppression (CD4 count <200 cells/µL).

S: Subjective

The patient notices new, white lesions on the tongue that cannot be wiped off or removed by scraping or brushing. The OHL lesions usually are asymptomatic, but occasionally may cause alteration in taste, discomfort, or other symptoms.

O: Objective

Perform a focused examination of the oropharynx. OHL appears as unilateral or bilateral white plaques or papillary lesions on the lateral, dorsal, or ventral surfaces of the tongue or on buccal mucosa. The lesions may vary in appearance from smooth, flat, small lesions to irregular, "hairy" or "verrucous" lesions with prominent vertical folds or projections.

A: Assessment

A partial differential diagnosis for OHL includes:

• Oral candidiasis
• Squamous cell carcinoma
• Geographic tongue
• Lichen planus
• Smoker's leukoplakia
• Epithelial dysplasia
• White sponge nevus

P: Plan

Diagnostic Evaluation

A presumptive diagnosis of OHL usually is made on the basis of the clinical appearance of the lesions. Because OHL is often confused with candidiasis, the diagnosis of OHL should be considered for lesions that resemble oral candidiasis but do not respond to treatment for candidiasis (see chapter Candidiasis, Oral and Esophageal ). Definitive diagnosis of OHL requires biopsy and demonstration of EBV.

• Biopsy lesions if they are ulcerated or unusual in appearance, to distinguish OHL from cancer or other causes.

Treatment

• Because OHL usually is asymptomatic, specific treatment generally is not necessary.
• Consider initiation of HIV treatment (antiretroviral therapy [ART]), if otherwise indicated, for immune system reconstitution. OHL may respond to ART.
• If specific treatment is required, the following may be considered. Relapse is common after discontinuation of treatment.
  • Acyclovir 800 mg orally 5 times per day for 2 weeks; famciclovir and valacyclovir may be considered.
  • Topical tretinoin (Retin-A) 0.025-0.05% solution, podophyllin 25% in tincture of benzoin, and other treatments also have been used.
  • For relapse of severe OHL, consider maintenance therapy with high-dose acyclovir, famciclovir, or valacyclovir.
• For severe symptomatic cases, surgical treatment (cryosurgery, excision, etc) may provide temporary resolution.
• Candidiasis may be present concurrently; treat candidiasis if it is present (see chapter Candidiasis, Oral and Esophageal ).

Patient Education

• Advise the patient that OHL rarely is a problem in itself, but may be a marker of HIV progression.
• If treatment is given, review possible drug side effects and interactions, and advise the patient to call if new symptoms develop.
• Instruct the patient to comply with regular dental and medical care regimens.

References

• Agbelusi GA, Wright AA. Oral lesions as indicators of HIV infection among routine dental patients in Lagos, Nigeria .Oral Dis. 2005 Nov;11(6):370-3.
• Coogan MM, Greenspan J, Challacombe SJ. Oral lesions in infection with human immunodeficiency virus . Bull World Health Organ. 2005 Sep;83(9):700-6. Epub 2005 Sep 30.
• Greenspan D. Oral manifestations of AIDS . AIDS Clinical Care. 1989;6:45-46.
• Greenspan JS, Greenspan D. Oral Complications of HIV Infection . In: Sande MA and Volberding PA, eds. Medical Management of AIDS, 6th ed . Philadelphia: WB Saunders; 1999:157-169.
• Kufe DW, Pollock RE, Bast RC Jr., et al, eds. Cancer Medicine, 6th ed . Lewiston, NY: BC Decker Inc.; 2003.
• Sande MA, Gilbert DN, Moellering RC Jr. The Sanford Guide to HIV/AIDS Therapy, 10th ed . Hyde Park, VT: Antimicrobial Therapy, Inc.; 2001.