Hairy leukoplakia
| Hairy leukoplakia | |
|---|---|
| Other names | Oral hairy leukoplakia,[1]: 385 OHL, orHIV-associated hairy leukoplakia[2] |
| Specialty | Gastroenterology,dentistry |
Hairy leukoplakiais a white patch on the side of the tongue with a corrugated or hairy appearance. It is caused byEpstein-Barr virus(EBV) and occurs usually in persons who areimmunocompromised,especially those withhuman immunodeficiency virusinfection/acquired immunodeficiency syndrome(HIV/AIDS). The whitelesion,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 ofleukoplakiais 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 thelateralsurfaces of the tongue, although rarely it may occur on thebuccal mucosa,soft palate,pharynxoresophagus.[5]The lesion may grow to involve thedorsalsurface of the tongue. The texture is vertically corrugated ( "hairy" ) or thickly furrowed and shaggy in appearance.[5]
Causes
[edit]The white appearance is created byhyperkeratosis(overproduction ofkeratin) andepithelialhyperplasia.[5]The causative agent implicated is Epstein-Barr virus, the same virus that causesinfectious 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 ofB lymphocytes.[6]The virus also causeslytic infectionin theoropharynx,but is kept in check by a normal, functioningimmune 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 chronicgraft 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 byin situ hybridization,polymerase chain reaction,immunohistochemistry,Southern blotting,orelectron microscopy) and HIV serotesting.[7]When clinical appearance alone is used to diagnose OHL, there is afalse positiverate 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 tissuebiopsyis carried out, thehistopathologicappearance is of hyperplastic and parakeratinized epithelium, with "balloon cells" (lightly staining cells) in the upperstratum spinosumand "nuclear beading" in the superficial layers (scattered cells with peripheral margination ofchromatinand clear nuclei, created by displacement of chromatin to the peripheral nucleus by EBV replication).Candidausually is seen growing in the parakeratin layer, but there are no normal inflammatory reactions to this in the tissues.[5]There is nodysplasia(OHL is not apremalignantlesion).[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 anopportunistic,viraldisease. Hairy leukoplakia occurs on the tongue and has a similar name tohairy 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 doseacyclovirordesiclovirbut recurs once this therapy is stopped, or as the underlying immunocompromise worsens.[8][5]Topicaluse ofpodophyllumresin orretinoidshas also been reported to produce temporary remission.[5]
Antiretroviral drugssuch aszidovudinemay be effective in producing a significant regression of OHL.[clarification needed][5]Recurrence of the lesion may also signify thathighly 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 withoral 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 theCD4count 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 andnecrotizing 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 byDeborah GreenspanandJohn S. Greenspan,and in 1985 they identified a connection between it andEpstein-Barr virus(EBV).[11]Oral hairy leukoplakia was first described by Greenspanet al.in 1984,[12]a few years after the start of theAIDS 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.ISBN978-0-7216-2921-6.
- ^Cawson RA, Odell EW, Porter S (2002).Cawsonś essentials of oral pathology and oral medicine(7th ed.). Edinburgh: Churchill Livingstone. pp. 223, 224.ISBN978-0443071065.
- ^"Leukoplakia".The Lecturio Medical Concept Library.Retrieved1 August2021.
- ^abcCherry-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.PMC2568277.PMID12656429.
- ^abcdefghijklNeville BW, Damm DD, Allen CM, Bouquot JE (2002).Oral & maxillofacial pathology(2nd ed.). Philadelphia: W.B. Saunders. pp.241–242.ISBN978-0721690032.
- ^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.PMC1907346.PMID11227065.
- ^abcdefScully C (2008).Oral and maxillofacial medicine: the basis of diagnosis and treatment(2nd ed.). Edinburgh: Churchill Livingstone. pp. 216, 308, 310–312.ISBN9780443068188.
- ^abcdefgChapple, 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.PMC1744197.PMID11026876.
- ^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.PMC1496917.PMID9502375.
- ^"Pioneering AIDS Researcher Receives Major Accolade | UC San Francisco".April 15, 2022. Archived fromthe originalon 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.PMID6148571.S2CID7928436.