Hairy leukoplakia: Difference between revisions
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{{Short description|Benign lesion on the side of the tongue due to Epstein-Barr virus}} |
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{{Distinguish|Hairy tongue}} |
{{Distinguish|Hairy tongue}} |
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<!-- another tongue condition with "hairy" in the name, but completely different etiology --> |
<!-- another tongue condition with "hairy" in the name, but completely different etiology --> |
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{{Infobox medical condition (new) |
{{Infobox medical condition (new) |
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| name = Hairy leukoplakia |
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| synonyms = '''Oral hairy leukoplakia''',<ref name="Andrews">{{cite book |author1=James, William D. |author2=Berger, Timothy G. |title=Andrews' Diseases of the Skin: clinical Dermatology |publisher=Saunders Elsevier |year=2006 |isbn=978-0-7216-2921-6 |display-authors=etal}}</ref>{{rp|385}} OHL, or '''HIV-associated hairy leukoplakia'''<ref name="Cawson 2002">{{cite book|vauthors=Cawson RA, Odell EW, Porter S |title=Cawsonś essentials of oral pathology and oral medicine.|year=2002|publisher=Churchill Livingstone|location=Edinburgh|isbn=978-0443071065|pages=223, 224|edition=7th}}</ref> |
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'''Hairy leukoplakia''' |
'''Hairy leukoplakia''' is a white patch on the side of the tongue with a corrugated or hairy appearance. It is caused by [[Epstein-Barr virus]] (EBV) and occurs usually in persons who are [[immunocompromise]]d, especially those with [[human immunodeficiency virus]] infection/[[acquired immunodeficiency syndrome]] (HIV/AIDS). The white [[lesion]], which cannot be scraped off, is benign and does not require any treatment, although its appearance may have diagnostic and prognostic implications for the underlying condition. |
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Depending upon what definition of [[leukoplakia]] is used, hairy leukoplakia is sometimes considered a subtype of leukoplakia, or a distinct diagnosis. |
Depending upon what definition of [[leukoplakia]] is used, hairy leukoplakia is sometimes considered a subtype of leukoplakia, or a distinct diagnosis.<ref>{{cite web |url=https://www.lecturio.com/concepts/leukoplakia/ | title=Leukoplakia |website=The Lecturio Medical Concept Library |access-date= 1 August 2021}}</ref> |
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| ⚫ | |||
| ⚫ | In a classification of the oral lesions in HIV disease,<ref>EC Clearinghouse. Oral Problems Related to HIV Infection, revised classification.</ref> OHL is grouped as "lesions strongly associated with HIV infection" (group I).<ref name="Chapple 2000">{{cite journal|last=Chapple|first=IL|author2=Hamburger, J|title=The significance of oral health in HIV disease.|journal=Sexually |
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==Signs and symptoms== |
==Signs and symptoms== |
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==Causes== |
==Causes== |
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The white appearance is created by [[hyperkeratosis]] (overproduction of [[keratin]]) and [[epithelium|epithelial]] [[hyperplasia]].<ref name="Neville 2002">{{cite book|vauthors=Neville BW, Damm DD, Allen CM, Bouquot JE|title=Oral & maxillofacial pathology|year=2002|publisher=W.B. Saunders|location=Philadelphia|isbn= |
The white appearance is created by [[hyperkeratosis]] (overproduction of [[keratin]]) and [[epithelium|epithelial]] [[hyperplasia]].<ref name="Neville 2002">{{cite book|vauthors=Neville BW, Damm DD, Allen CM, Bouquot JE|title=Oral & maxillofacial pathology|url=https://archive.org/details/oralmaxillofacia00nevi|url-access=registration|year=2002|publisher=W.B. Saunders|location=Philadelphia|isbn=978-0721690032|pages=[https://archive.org/details/oralmaxillofacia00nevi/page/n253 241]–242|edition=2nd}}</ref> The causative agent implicated is Epstein-Barr virus, the same virus that causes [[infectious mononucleosis]] (glandular fever). After the primary EBV infection has been overcome, the virus will persist for the rest of the host's life and "hides" from the immune system by latent infection of [[B lymphocytes]].<ref name="Gulley 2001">{{cite journal|last=Gulley|first=ML|title=Molecular diagnosis of Epstein-Barr virus-related diseases.|journal=The Journal of Molecular Diagnostics|date=February 2001|volume=3|issue=1|pages=1–10|pmid=11227065|pmc=1907346|doi=10.1016/s1525-1578(10)60642-3}}</ref> The virus also causes [[lytic cycle|lytic infection]] in the [[oropharynx]], but is kept in check by a normal, functioning [[immune system]]. Uncontrolled lytic infection is manifested as oral hairy leukoplakia in immunocompromised hosts. OHL usually arises where the immunocompromise is secondary to HIV/AIDS.<ref name="Neville 2002" /> Rarely are other causes of immunocompromise associated with OHL, but it has been reported in people who have received transplants<!-- <ref name="Neville 2002" /> --> and are taking immunosuppressive medication. OHL may also accompany chronic [[graft versus host disease]].<ref name="Scully 2008" /> Even more rare are reports of OHL in persons with competent immune systems.<ref name="Neville 2002" /> |
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==Diagnosis== |
==Diagnosis== |
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The white lesion cannot be wiped away,<ref name="Scully 2008" /> unlike some other common oral white lesions, e.g. [[oral candidiasis|pseudomembranous candidiasis]], and this may aid in the diagnosis. Diagnosis of OHL is mainly clinical, but can be supported by proof of EBV in the lesion (achieved by [[in situ hybridization]], [[polymerase chain reaction]], [[immunohistochemistry]], [[Southern blotting]], or [[electron microscopy]]) and HIV serotesting.<ref name="Scully 2008" /> When clinical appearance alone is used to diagnose OHL, there is a [[false positive]] rate of 17% compared to more objective methods.<ref name="Chapple 2000" /> The appearance of OHL in a person who is known to be infected with HIV does not usually require further diagnostic tests as the association is well known. OHL in persons with no known cause of immunocompromise usually triggers investigations to look for an underlying cause. If tissue [[biopsy]] is carried out, the [[histopathology|histopathologic]] appearance is of hyperplastic and parakeratinized epithelium, with "balloon cells" (lightly staining cells) in the upper [[stratum spinosum]] and "nuclear beading" in the superficial layers (scattered cells with peripheral margination of [[chromatin]] and clear nuclei, created by displacement of chromatin to the peripheral nucleus by EBV replication). [[Candida (fungus)|Candida]] usually is seen growing in the parakeratin layer, but there are no normal inflammatory reactions to this in the tissues.<ref name="Neville 2002" /> There is no [[dysplasia]] (OHL is not a [[premalignant]] lesion).<ref name="Neville 2002" /> |
The white lesion cannot be wiped away,<ref name="Scully 2008" /> unlike some other common oral white lesions, e.g. [[oral candidiasis|pseudomembranous candidiasis]], and this may aid in the diagnosis. Diagnosis of OHL is mainly clinical, but can be supported by proof of EBV in the lesion (achieved by [[in situ hybridization]], [[polymerase chain reaction]], [[immunohistochemistry]], [[Southern blotting]], or [[electron microscopy]]) and HIV serotesting.<ref name="Scully 2008" /> When clinical appearance alone is used to diagnose OHL, there is a [[false positive]] rate of 17% compared to more objective methods.<ref name="Chapple 2000" /> The appearance of OHL in a person who is known to be infected with HIV does not usually require further diagnostic tests as the association is well known. OHL in persons with no known cause of immunocompromise usually triggers investigations to look for an underlying cause. If tissue [[biopsy]] is carried out, the [[histopathology|histopathologic]] appearance is of hyperplastic and parakeratinized epithelium, with "balloon cells" (lightly staining cells) in the upper [[stratum spinosum]] and "nuclear beading" in the superficial layers (scattered cells with peripheral margination of [[chromatin]] and clear nuclei, created by displacement of chromatin to the peripheral nucleus by EBV replication). [[Candida (fungus)|Candida]] usually is seen growing in the parakeratin layer, but there are no normal inflammatory reactions to this in the tissues.<ref name="Neville 2002" /> There is no [[dysplasia]] (OHL is not a [[premalignant]] lesion).<ref name="Neville 2002" /> |
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| ⚫ | |||
| ⚫ | In a classification of the oral lesions in HIV disease,<ref>EC Clearinghouse. Oral Problems Related to HIV Infection, revised classification.</ref> OHL is grouped as "lesions strongly associated with HIV infection" (group I).<ref name="Chapple 2000">{{cite journal|last=Chapple|first=IL|author2=Hamburger, J|title=The significance of oral health in HIV disease.|journal=Sexually Transmitted Infections|date=August 2000|volume=76|issue=4|pages=236–43|pmid=11026876|pmc=1744197|doi=10.1136/sti.76.4.236}}</ref> It could also be classed as an [[opportunistic infection|opportunistic]], [[virus|viral]] disease. Hairy leukoplakia occurs on the tongue and has a similar name to [[hairy tongue]], but these are separate conditions with different causes.{{citation needed|date=January 2021}} |
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==Treatment== |
==Treatment== |
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Treatment is not necessary since the lesion is benign, however the person may have |
Treatment is not necessary since the lesion is benign, however, the person may have aesthetic concerns about the appearance. The condition often resolves rapidly with high dose [[acyclovir]] or [[desiclovir]] but recurs once this therapy is stopped, or as the underlying immunocompromise worsens.<ref name="Chapple 2000" /><ref name="Neville 2002" /> [[Topical medication|Topical]] use of [[podophyllum]] resin or [[retinoid]]s has also been reported to produce temporary remission.<ref name="Neville 2002" /> |
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[[Antiretroviral drug]]s such as [[zidovudine]] may be effective in producing a significant regression of OHL.{{clarify|reason=In HIV-associated cases only, or in general?|date=August 2022}}<ref name="Neville 2002" /> Recurrence of the lesion may also signify that [[highly active antiretroviral therapy]] (HAART) is becoming ineffective.<ref name="Cherry-Peppers 2003" /> |
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==Prognosis== |
==Prognosis== |
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==Epidemiology== |
==Epidemiology== |
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Hairy leukoplakia is one of the most common oral manifestations of HIV/AIDS, along with [[oral candidiasis]].<ref name="Scully 2008" /> It is the most common HIV/AIDS related condition caused by EBV, although EBV associated lymphomas may also occur.<ref name="Neville 2002" /> OHL mainly occurs in adult males, less commonly in adult females and rarely in children.<ref name="Chapple 2000" /> The incidence rises as the [[CD4]] count falls,<ref name="Chapple 2000" /> and the appearance of OHL may |
Hairy leukoplakia is one of the most common oral manifestations of HIV/AIDS, along with [[oral candidiasis]].<ref name="Scully 2008" /> It is the most common HIV/AIDS related condition caused by EBV, although EBV associated lymphomas may also occur.<ref name="Neville 2002" /> OHL mainly occurs in adult males, less commonly in adult females and rarely in children.<ref name="Chapple 2000" /> The incidence rises as the [[CD4]] count falls,<ref name="Chapple 2000" /> and the appearance of OHL may signify progression of HIV to AIDS.<ref name="Jung 1998">{{cite journal|last=Jung|first=AC|author2=Paauw, DS|title=Diagnosing HIV-related disease: using the CD4 count as a guide.|journal=Journal of General Internal Medicine|date=February 1998|volume=13|issue=2|pages=131–6|doi=10.1046/j.1525-1497.1998.00031.x|pmid=9502375|pmc=1496917}}</ref> A study from 2001 reported a significant decrease in the incidence of some oral manifestations of AIDS (including OHL and [[Necrotizing periodontal diseases#Necrotizing ulcerative periodontitis|necrotizing ulcerative periodontitis]]), which was attributed to the use of HAART, whilst the incidence of other HIV-associated oral lesions did not alter significantly.<ref name="Cherry-Peppers 2003">{{cite journal|last=Cherry-Peppers|first=G|author2=Daniels, CO |author3=Meeks, V |author4=Sanders, CF |author5= Reznik, D |title=Oral manifestations in the era of HAART.|journal=Journal of the National Medical Association|date=February 2003|volume=95|issue=2 Suppl 2|pages=21S–32S|pmid=12656429|pmc=2568277}}</ref> |
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==History== |
==History== |
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Oral hairy leukoplakia was first described by Greenspan ''et al.'' in 1984,<ref>{{cite journal|last=Greenspan|first=D|author2=Greenspan, JS|author3=Conant, M|author4=Petersen, V|author5=Silverman S Jr|author6=de Souza, Y|title=Oral "hairy" leucoplakia in male homosexuals: evidence of association with both papillomavirus and a herpes-group virus.|journal=Lancet|date=Oct 13, 1984|volume=2|issue=8407|pages=831–4|pmid=6148571|doi=10.1016/s0140-6736(84)90872-9}}</ref><!-- landmark primary source included for use in history section only --> a few years after the start of the [[AIDS epidemic]]. A link with OHL was not initially reported as scientific understanding of HIV/AIDS was just beginning to |
Oral hairy leukoplakia was discovered by [[Deborah Greenspan]] and [[John S. Greenspan]], and in 1985 they identified a connection between it and [[Epstein-Barr virus]] (EBV).<ref>{{Cite web |url=https://www.ucsf.edu/news/2012/07/104262/pioneering-aids-researcher-receives-major-accolade |title=Pioneering AIDS Researcher Receives Major Accolade | UC San Francisco |date=April 15, 2022 |website= |archive-url=https://web.archive.org/web/20220415004115/https://www.ucsf.edu/news/2012/07/104262/pioneering-aids-researcher-receives-major-accolade |archive-date=15 April 2022 |url-status=dead}}</ref> Oral hairy leukoplakia was first described by Greenspan ''et al.'' in 1984,<ref>{{cite journal|last=Greenspan|first=D|author2=Greenspan, JS|author3=Conant, M|author4=Petersen, V|author5=Silverman S Jr|author6=de Souza, Y|title=Oral "hairy" leucoplakia in male homosexuals: evidence of association with both papillomavirus and a herpes-group virus.|journal=Lancet|date=Oct 13, 1984|volume=2|issue=8407|pages=831–4|pmid=6148571|doi=10.1016/s0140-6736(84)90872-9|s2cid=7928436}}</ref><!-- landmark primary source included for use in history section only --> a few years after the start of the [[AIDS epidemic]]. A link with OHL was not initially reported as scientific understanding of HIV/AIDS was just beginning to develop at that time. It was subsequently thought to occur only in HIV-infected, homosexual males, however, this is now known to not always be the case.<ref name="Chapple 2000" /> |
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==Research directions== |
==Research directions== |
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== References == |
== References == |
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{{Reflist}} |
{{Reflist}} |
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== External links == |
== External links == |
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{{Medical resources |
{{Medical resources |
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| ICD10 = {{ICD10|K|13|3|k|00}} |
| ICD10 = {{ICD10|K|13|3|k|00}} |
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| ICD9 = {{ICD9|528.6}} |
| ICD9 = {{ICD9|528.6}} |
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| ICDO = |
| ICDO = |
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| OMIM = |
| OMIM = |
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| DiseasesDB = 5594 |
| DiseasesDB = 5594 |
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| MedlinePlus = |
| MedlinePlus = |
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| eMedicineSubj = med |
| eMedicineSubj = med |
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| eMedicineTopic = 938 |
| eMedicineTopic = 938 |
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| MeshID = D017733 |
| MeshID = D017733 |
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}} |
}} |
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{{Oral pathology}} |
{{Oral pathology}} |
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[[Category:Conditions of the mucous membranes]] |
[[Category:Conditions of the mucous membranes]] |
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[[Category:HIV/AIDS]] |
[[Category:HIV/AIDS]] |
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[[Category:Epstein–Barr |
[[Category:Epstein–Barr virus–associated diseases]] |
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[[Category:Oral mucosal pathology]] |
[[Category:Oral mucosal pathology]] |
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[[Category:Tongue disorders]] |
[[Category:Tongue disorders]] |
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Latest revision as of 23:08, 19 September 2023
| Hairy leukoplakia | |
|---|---|
| Other names | Oral hairy leukoplakia,[1]: 385 OHL, or HIV-associated hairy leukoplakia[2] |
| Specialty | Gastroenterology, dentistry  |
Hairy leukoplakia is a white patch on the side of the tongue with a corrugated or hairy appearance. It is caused by Epstein-Barr virus (EBV) and occurs usually in persons who are immunocompromised, especially those with human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS). The white lesion, which cannot be scraped off, is benign and does not require any treatment, although its appearance may have diagnostic and prognostic implications for the underlying condition.
Depending upon what definition of leukoplakia is used, hairy leukoplakia is sometimes considered a subtype of leukoplakia, or a distinct diagnosis.[3]
Signs and symptoms
[edit]There are no symptoms associated with the lesion itself,[4] although many and varied symptoms and signs may be associated with the underlying cause of immunosuppression. The lesion is a white patch, which almost exclusively occurs on the lateral surfaces of the tongue, although rarely it may occur on the buccal mucosa, soft palate, pharynx or esophagus.[5] The lesion may grow to involve the dorsal surface of the tongue. The texture is vertically corrugated ("hairy") or thickly furrowed and shaggy in appearance.[5]
Causes
[edit]The white appearance is created by hyperkeratosis (overproduction of keratin) and epithelial hyperplasia.[5] The causative agent implicated is Epstein-Barr virus, the same virus that causes infectious mononucleosis (glandular fever). After the primary EBV infection has been overcome, the virus will persist for the rest of the host's life and "hides" from the immune system by latent infection of B lymphocytes.[6] The virus also causes lytic infection in the oropharynx, but is kept in check by a normal, functioning immune system. Uncontrolled lytic infection is manifested as oral hairy leukoplakia in immunocompromised hosts. OHL usually arises where the immunocompromise is secondary to HIV/AIDS.[5] Rarely are other causes of immunocompromise associated with OHL, but it has been reported in people who have received transplants and are taking immunosuppressive medication. OHL may also accompany chronic graft versus host disease.[7] Even more rare are reports of OHL in persons with competent immune systems.[5]
Diagnosis
[edit]The white lesion cannot be wiped away,[7] unlike some other common oral white lesions, e.g. pseudomembranous candidiasis, and this may aid in the diagnosis. Diagnosis of OHL is mainly clinical, but can be supported by proof of EBV in the lesion (achieved by in situ hybridization, polymerase chain reaction, immunohistochemistry, Southern blotting, or electron microscopy) and HIV serotesting.[7] When clinical appearance alone is used to diagnose OHL, there is a false positive rate of 17% compared to more objective methods.[8] The appearance of OHL in a person who is known to be infected with HIV does not usually require further diagnostic tests as the association is well known. OHL in persons with no known cause of immunocompromise usually triggers investigations to look for an underlying cause. If tissue biopsy is carried out, the histopathologic appearance is of hyperplastic and parakeratinized epithelium, with "balloon cells" (lightly staining cells) in the upper stratum spinosum and "nuclear beading" in the superficial layers (scattered cells with peripheral margination of chromatin and clear nuclei, created by displacement of chromatin to the peripheral nucleus by EBV replication). Candida usually is seen growing in the parakeratin layer, but there are no normal inflammatory reactions to this in the tissues.[5] There is no dysplasia (OHL is not a premalignant lesion).[5]
Classification
[edit]In a classification of the oral lesions in HIV disease,[9] OHL is grouped as "lesions strongly associated with HIV infection" (group I).[8] It could also be classed as an opportunistic, viral disease. Hairy leukoplakia occurs on the tongue and has a similar name to hairy tongue, but these are separate conditions with different causes.[citation needed]
Treatment
[edit]Treatment is not necessary since the lesion is benign, however, the person may have aesthetic concerns about the appearance. The condition often resolves rapidly with high dose acyclovir or desiclovir but recurs once this therapy is stopped, or as the underlying immunocompromise worsens.[8][5] Topical use of podophyllum resin or retinoids has also been reported to produce temporary remission.[5]
Antiretroviral drugs such as zidovudine may be effective in producing a significant regression of OHL.[clarification needed][5] Recurrence of the lesion may also signify that highly active antiretroviral therapy (HAART) is becoming ineffective.[4]
Prognosis
[edit]The oral lesion itself is benign and self-limiting,[7] however this may not necessarily be the case for the underlying cause of immunocompromise. For instance, OHL with HIV/AIDS is a predictor of bad prognosis,[7] (i.e. severe immunosuppression and advanced disease).[5]
Epidemiology
[edit]Hairy leukoplakia is one of the most common oral manifestations of HIV/AIDS, along with oral candidiasis.[7] It is the most common HIV/AIDS related condition caused by EBV, although EBV associated lymphomas may also occur.[5] OHL mainly occurs in adult males, less commonly in adult females and rarely in children.[8] The incidence rises as the CD4 count falls,[8] and the appearance of OHL may signify progression of HIV to AIDS.[10] A study from 2001 reported a significant decrease in the incidence of some oral manifestations of AIDS (including OHL and necrotizing ulcerative periodontitis), which was attributed to the use of HAART, whilst the incidence of other HIV-associated oral lesions did not alter significantly.[4]
History
[edit]Oral hairy leukoplakia was discovered by Deborah Greenspan and John S. Greenspan, and in 1985 they identified a connection between it and Epstein-Barr virus (EBV).[11] Oral hairy leukoplakia was first described by Greenspan et al. in 1984,[12] a few years after the start of the AIDS epidemic. A link with OHL was not initially reported as scientific understanding of HIV/AIDS was just beginning to develop at that time. It was subsequently thought to occur only in HIV-infected, homosexual males, however, this is now known to not always be the case.[8]
Research directions
[edit]It has been suggested that OHL be renamed according to its causative factor as “EBV leucoplakia”.[8]
References
[edit]- ^ James, William D.; Berger, Timothy G.; et al. (2006). Andrews' Diseases of the Skin: clinical Dermatology. Saunders Elsevier. ISBN 978-0-7216-2921-6.
- ^ Cawson RA, Odell EW, Porter S (2002). Cawsonś essentials of oral pathology and oral medicine (7th ed.). Edinburgh: Churchill Livingstone. pp. 223, 224. ISBN 978-0443071065.
- ^ "Leukoplakia". The Lecturio Medical Concept Library. Retrieved 1 August 2021.
- ^ a b c Cherry-Peppers, G; Daniels, CO; Meeks, V; Sanders, CF; Reznik, D (February 2003). "Oral manifestations in the era of HAART". Journal of the National Medical Association. 95 (2 Suppl 2): 21S–32S. PMC 2568277. PMID 12656429.
- ^ a b c d e f g h i j k l Neville BW, Damm DD, Allen CM, Bouquot JE (2002). Oral & maxillofacial pathology (2nd ed.). Philadelphia: W.B. Saunders. pp. 241–242. ISBN 978-0721690032.
- ^ Gulley, ML (February 2001). "Molecular diagnosis of Epstein-Barr virus-related diseases". The Journal of Molecular Diagnostics. 3 (1): 1–10. doi:10.1016/s1525-1578(10)60642-3. PMC 1907346. PMID 11227065.
- ^ a b c d e f Scully C (2008). Oral and maxillofacial medicine : the basis of diagnosis and treatment (2nd ed.). Edinburgh: Churchill Livingstone. pp. 216, 308, 310–312. ISBN 9780443068188.
- ^ a b c d e f g Chapple, IL; Hamburger, J (August 2000). "The significance of oral health in HIV disease". Sexually Transmitted Infections. 76 (4): 236–43. doi:10.1136/sti.76.4.236. PMC 1744197. PMID 11026876.
- ^ EC Clearinghouse. Oral Problems Related to HIV Infection, revised classification.
- ^ Jung, AC; Paauw, DS (February 1998). "Diagnosing HIV-related disease: using the CD4 count as a guide". Journal of General Internal Medicine. 13 (2): 131–6. doi:10.1046/j.1525-1497.1998.00031.x. PMC 1496917. PMID 9502375.
- ^ "Pioneering AIDS Researcher Receives Major Accolade | UC San Francisco". April 15, 2022. Archived from the original on 15 April 2022.
- ^ Greenspan, D; Greenspan, JS; Conant, M; Petersen, V; Silverman S Jr; de Souza, Y (Oct 13, 1984). "Oral "hairy" leucoplakia in male homosexuals: evidence of association with both papillomavirus and a herpes-group virus". Lancet. 2 (8407): 831–4. doi:10.1016/s0140-6736(84)90872-9. PMID 6148571. S2CID 7928436.