White Patches  (incl. Lichen Planus)

Important factors in history and examination

¨ Painful? Any history of trauma?

¨ Smoking and drinking habits

¨ Determine whether the patch is removable with a gauze or tongue spatula

¨ Site – high risk area of mouth – the ‘Well’

¨ Note any mucosal ulceration and erythema

¨ Homogeneous or not?

¨ Skin conditions associated

¨ Palpate for cervical lymph node enlargement

 

Differential Diagnosis

Removable white patches

             Epithelial or food debris

             Leukoedema (congenital benign, faint whiteness of mucosa, disappears if mucosa stretched)

             Chemical trauma (aspirin can cause epithelial necrosis, sloughing, ulceration)

             Pseudomembraneous candidiasis / candidosis

Non-removable white patches

¨ Congential

             Fordyce Spots (ectopic sebaceous glands)

             White sponge naevus (defect of keratin - thickened, bilateral, often buccal mucosa)

             Dyskeratosis congenita (rare, potentially malignant)

 

 

 

 

 

 

 

 

¨ Acquired

             -Traumatic

Frictional keratosis

cheek biting, sharp tooth, ill-fitting denture, often seen along occlusal line

Smoker’s keratosis

Nicotinic stomatitis – diffusely white palate with red dots showing dilated minor salivary glands

Submucous fibrosis

 

             -Infective

Candidal leukoplakia

may be associated with an increased risk of malignant change – see section on Candidiasis

Syphilitic leukoplakia

malignant potential high, rarely seen now – feature of tertiary syphilis, commonly dorsum of tongue

Oral hairy leukoplakia

EBV causes, corrugated surface, almost always margins of tongue, often immunocompromised patients – especially HIV

 

             -Dermatological

Lichen planus

(See later for more detail)

and lichenoid drug reactions

can be impossible to differentiate between

Systemic lupus erythematosis

oral lesions seen in up to 20% of patients with SLE; symmetrically distributed erythematous areas, erosions or white patches, can be difficult to distinguish from Lichen Planus, palate a common site

Discoid lupus erythematosus

mostly affects buccal mucosa, alveolar ridge and vermillion of lip; central atrophic area with white striae radiating perpendicular to edge of lesion; can be indistinguishable from SLE (see picture above)

 

             -Miscellaneous

             Skin grafts

             Vitamin A deficiency

             Neoplasia and premalignant conditions

             Leukoplakia

             Speckled leukoplakia (more serious, high prevalence of malignant change, see picture above)

             Erythroplakia (85% are severely dysplastic or frankly malignant)

Squamous cell carcinoma

 

Idiopathic Keratoses

Some leukoplakias arise in the absence of identifiable predisposing factors – 70% benign

Those with the greatest malignant potential are:-

¨ Speckled, nodular, verrucous lesions

¨ In at-risk sites – lateral tongue, ventral tongue, floor of mouth and soft palate

¨ Associated with Candida

¨ Admixture with red lesions

¨ A raised lesion

Rates of up to 30% malignant transformation

Biopsy is indicated, especially if high risk of malignant transformation (see above)

 

Management

Consider site, histology, age and health of patient, in conjunction with aetiological factors before deciding on long-term observation or active treatment.

Stop patient from smoking and 60% will disappear.

Observe with clinical examination, cytology or biopsy for changes.

Treatment options include cryosurgery, surgical excision, topical bleomycin, (after removal of aetiological factors.)

Follow up at three-monthly intervals.

 

 

LICHEN PLANUS

One of the most prevalent mucocutaneous disorders (1-2%)

Cause unknown – although immunologically mediated with no defined auto-AB’s

30-65 years, slight increased female predisposition

Stress can precipitate, candidosis can co-exist

Diabetes, drugs, dental fillings, and Hepatitis C should be excluded

Often white patches or striae, can affect any oral site

Often symmetric and bilateral distribution

6 forms have been described:- atrophic, reticular (striae), papular, plaque-like, erosive, bullous (rare)

Cutaneous lesions:- purple papules on flexor sufaces of arms/legs

Oral LP can be accompanied by vulvovaginal lesions

Pre-existing L.P. has occasionally been associated with development of oral cancer, especially if known risk factors are present.

Biopsy to  confirm and then regular review, advisable to biopsy if change in clinical appearance

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment :-

¨ Chlorhexidine mouthwash

¨ Topical steroid therapy

             – Corlan pellets (2.5mg hydrocortisone hemisuccinate)

             - Betamethasone (0.5mg tablets allowed to dissolve on affected area, qds)

¨ Intra-lesional Triamcinolone

¨ Short course of systemic steroid therapy (if acute symptoms of widespread ulceration,        erythema, pain)

¨ Cyclosporin mouthwash

¨ Topical tacrolimus

¨ Systemic mycophenolate

¨ Clobetasol 0.05% cream (used if desquamative gingivitis present).

A number of conditions of the oral mucosa may present as white patches (0.1%).  Although the majority of white patches are of little significance, certain lesions are associated with premalignancy or malignancy.

Whenever there is uncertainty about the clinical diagnosis of a white patch it is essential to obtain a definitive histological diagnosis (biopsy).

Leukoplakia is a term that describes a white patch on the oral mucosa that cannot be wiped off and is not attributable to any other diagnosis.  It is thus a clinical diagnosis and can only be made by exclusion.

White Sponge Naevus

Smokers Kerotosis

DLE

Atrophic/ erosive type

Atrophic type with  striae surrounding

Papular Lichen Planus