White lesions(collection)

WHITEWHITE && REDRED LESIONSLESIONS

BYBY: :

DR. NAYROZ ABDEL-FATTAHDR. NAYROZ ABDEL-FATTAH

White lesions White lesions may bemay be::

HereditaryHereditary Reactive \ inflammatoryReactive \ inflammatory Infectious Infectious Idiopathic leukoplakia Idiopathic leukoplakia ErythroplakiaErythroplakia Lichen planus – lichenoid reaction Lichen planus – lichenoid reaction Lupus erythematosusLupus erythematosus MiscellaneousMiscellaneous

Hereditary white lesionsHereditary white lesions::

1.1. LeukodemaLeukodema

2.2. White spongy nevusWhite spongy nevus

3.3. Hereditary benign intraepithelial Hereditary benign intraepithelial dyskeratosisdyskeratosis

4.4. Darrier’s diseaseDarrier’s disease


Leukodema:Leukodema: Normal variation .Normal variation . Faint , white , Faint , white ,

diffuse , diffuse , numerous folds .numerous folds .

Dissappears upon Dissappears upon stretching .stretching .

No treatment – no No treatment – no malignant change malignant change ..


White spongy nevus:White spongy nevus: Oral mucosa – m.m of nose Oral mucosa – m.m of nose

, esophagus , rectum ., esophagus , rectum . At birth or at puberty.At birth or at puberty. Bilateral symmetric.Bilateral symmetric. White soft spongy or thick White soft spongy or thick

plaque.plaque. Buccal mucosa.Buccal mucosa. May be on ventral surfase May be on ventral surfase

of tongue,floor of of tongue,floor of mouth,labial mucosa,soft mouth,labial mucosa,soft palate,alveolar mucosa.palate,alveolar mucosa.

Asymptomatic – no Asymptomatic – no malignant transformation.malignant transformation.

HereditaryHereditary white lesions white lesions::

Hereditary benign intraepithelial Hereditary benign intraepithelial dyskeratosis:dyskeratosis:

1.1. Oral lesions: Oral lesions: thick ,corrugated ,asymptomatic thick ,corrugated ,asymptomatic white spongy plaques on buccal & labial m. white spongy plaques on buccal & labial m. Appears in 1Appears in 1stst year of life &gradually increase till year of life &gradually increase till teens – no treatment.teens – no treatment.

2.2. Eye lesions:Eye lesions: thick gelatinous foamy opaque thick gelatinous foamy opaque plaque adjacent to cornea – seasonal prominance plaque adjacent to cornea – seasonal prominance in spring & regression in summer – blindness – in spring & regression in summer – blindness – referral to ophthalmologist.referral to ophthalmologist.

HereditaryHereditary white lesions white lesions::

Darrier’s disease:Darrier’s disease:lesions start before age of 30 ys.- no treatment lesions start before age of 30 ys.- no treatment 1.1. Skin lesionsSkin lesions: : firm papules skin coloured ,yellow-brown, brown.firm papules skin coloured ,yellow-brown, brown. Coalescence of papules forms warty plaques.Coalescence of papules forms warty plaques. Found on scalp margins ,forehead, ears & nasolabial furrows.Found on scalp margins ,forehead, ears & nasolabial furrows.1.1. Oral lesions: Oral lesions: white papules on palate ,tongue ,buccal mucosa ,epiglottis ,pharyngeal wall white papules on palate ,tongue ,buccal mucosa ,epiglottis ,pharyngeal wall coalescence of papules forms patches similar to leukoplakia.coalescence of papules forms patches similar to leukoplakia.3.3. Nail lesions:Nail lesions: Broad white longitudinal bandBroad white longitudinal band Broad red longitudinal bandBroad red longitudinal band Sandwich of both with v-shaped nick at free marginSandwich of both with v-shaped nick at free margin4.4. Ear lesions: Ear lesions: Blockage of external auditory meatus by keratotic debrisBlockage of external auditory meatus by keratotic debris

Darrier’s diseaseDarrier’s disease::



Reactive & Inflammatory Reactive & Inflammatory white lesionswhite lesions : :

Frictional keratosisFrictional keratosis Cheek chewingCheek chewing Chemical injuriesChemical injuries Actinic keratosisActinic keratosis Smokeless tobacco-induced keratosisSmokeless tobacco-induced keratosis Stomatitis nicotineStomatitis nicotine

Frictional keratosisFrictional keratosis

White plaque White plaque related to source of related to source of mechanical mechanical irritation.irritation.

Treatment : Treatment : removal of removal of offending cause.offending cause.

Cheek chewingCheek chewing

Chronic irritationChronic irritation Mostly in people Mostly in people

under stressunder stress No treatment , may No treatment , may

be plastic occlusal be plastic occlusal night guardnight guard

Chemical burn (phenol)Chemical burn (phenol)

Transient Transient nonkeratotic lesion nonkeratotic lesion

due to caustic as due to caustic as formcresol, acid formcresol, acid etchant, hydrogen etchant, hydrogen perioxide, perioxide, asprin ,sodium asprin ,sodium hypochloritehypochlorite

Emollient agent as Emollient agent as methyl cellulose for methyl cellulose for treatmenttreatment

Aspirin burnAspirin burn

Actinic keratosisActinic keratosis

PremalignantPremalignant Due to long term Due to long term

sun exposuresun exposure Vermillion border Vermillion border

of lower lipof lower lip Treatment : Treatment :

surgerysurgery

Smokless tobacco induced Smokless tobacco induced keratosiskeratosis

In the area of In the area of tobacco contacttobacco contact

PrecancerousPrecancerous

May be wrinkled or May be wrinkled or foldedfolded

May be May be Accompanied by Accompanied by gingival gingival recessetion& perio-recessetion& perio-destructiondestruction

Stomatitis nicotinaStomatitis nicotina



Infectious white lesionsInfectious white lesions::

Oral hairy leukoplakiaOral hairy leukoplakia

Candidiasis Candidiasis

Hairy LeukoplakiaHairy Leukoplakia::

By epstain barr By epstain barr virus.virus.

In HIV patient.In HIV patient. Mainly on lateral Mainly on lateral

border or ventral border or ventral surface of the surface of the tonguetongue

Treatment: Treatment: antiviral drugs.antiviral drugs.

Oral candidosisOral candidosis::

Acute Acute Acute Acute

pseudomembranous pseudomembranous cand.(thrush)cand.(thrush)

Acute antibiotic Acute antibiotic stomatitis (atrophic or stomatitis (atrophic or erythamatous)erythamatous)

Chronic Chronic Denture induced Denture induced

stomatitisstomatitis Angular stomatitisAngular stomatitis Median rhomboid Median rhomboid

glossitisglossitis Candidal leukoplakia Candidal leukoplakia

(ch. Hyperplastic)(ch. Hyperplastic) Ch. Mucocutaneous Ch. Mucocutaneous

candidosiscandidosis Erythematous cand.Erythematous cand.

Acute pseudomembranous Acute pseudomembranous cand.(thrush):cand.(thrush):

PainlessPainless Soft friable creamy Soft friable creamy

plaqueplaque Easily wiped offEasily wiped off Prodrome : bad Prodrome : bad

taste or loss of taste or loss of sensationsensation

Lab. InvestigationLab. Investigation: :

Confirmation:Confirmation: Gm stained smear Gm stained smear

shows candidal shows candidal hyphaehyphae

Biopsy: hyperplastic Biopsy: hyperplastic epithelium, epithelium, inflammatory edema inflammatory edema & cells& cells

Staining with PAS Staining with PAS shows candidal shows candidal hyphaehyphae

Acute antibiotic stomatitis Acute antibiotic stomatitis (atrophic or erythamatous)(atrophic or erythamatous)::

Follow overuse of Follow overuse of antibioticsantibiotics

The whole mucosa: The whole mucosa: red & glazedred & glazed

Flecks of thrush Flecks of thrush Xerostomia Xerostomia

(sjogren syndrome) (sjogren syndrome)

Denture induced stomatitisDenture induced stomatitis::

Upper dentureUpper denture

Due to well fitting Due to well fitting denture cutting the denture cutting the washing effect of washing effect of salivasaliva

Painless Painless red areared area

http://images.google.com.eg/imgres?imgurl=http://www.swedishmedical.org/PERT/images/denture.jpg&imgrefurl=http://www.swedishmedical.org/PERT/tips/tip_jul_05.htm&usg=__TAXOJgzBr-pMkNFM5CK3O35fip0=&h=177&w=180&sz=9&hl=en&start=1&tbnid=h5JunUHmpSoMwM:&tbnh=99&tbnw=101&prev=/images%3Fq%3Ddenture%2Bstomatitis%26gbv%3D2%26hl%3Den

Angular stomatitisAngular stomatitis::

Leakage candida-Leakage candida-infected saliva at infected saliva at mouth anglesmouth angles

Low vertical Low vertical dimension & dimension &

loss of upper lip loss of upper lip support due to support due to underlying bone underlying bone resorptionresorption

http://pathmicro.med.sc.edu/lecture/images/chelitis.gif

Angular Cheilitis

Median rhomboid glossitisMedian rhomboid glossitis::

Red patch Red patch of of atrophic papillaeatrophic papillae

Central area of Central area of

dorsum of tonguedorsum of tongue

http://images.google.com.eg/imgres?imgurl=http://www.skinandaging.com/files/imagecache/normal/photos/92-dermdx-rhomboid_tongue.jpg&imgrefurl=http://www.skinandaging.com/article/7621&usg=__XhGXs_JhIQJfvHHYASqrss2HdW8=&h=262&w=350&sz=15&hl=en&start=24&tbnid=q8jmTV731GbGFM:&tbnh=90&tbnw=120&prev=/images%3Fq%3Dmedian%2Brhomboid%2Bglossitis%26gbv%3D2%26ndsp%3D20%26hl%3Den%26sa%3DN%26start%3D20

Chronic mucocutaneous Chronic mucocutaneous candidosiscandidosis::

Defect in cell Defect in cell mediated immunity mediated immunity or iron deficiencyor iron deficiency

Candidosis Candidosis endocrinopathy endocrinopathy syndrome: familial syndrome: familial autosomal autosomal recessive recessive

Chronic mucocutaneous candidiasis

Candidal leukoplakia (ch. Candidal leukoplakia (ch. Hyperplastic)Hyperplastic)::

Firm white Firm white leathery leathery plaquesplaques

Cheek ,lip ,tongue ,Cheek ,lip ,tongue ,palate palate

Invasion of candida Invasion of candida deeper in mucosa deeper in mucosa leads to leads to proliferative proliferative response response

Chronic hyperplastic candidiasis

Erythematous candidiasisErythematous candidiasis::

Red maculesRed macules

In HIV infectionIn HIV infection

Mainly on hard Mainly on hard palate , dorsum of palate , dorsum of tongue ,soft palatetongue ,soft palate



Idiopathic (true) leukoplakiaIdiopathic (true) leukoplakia::

White patch or White patch or plaqueplaque

Can’t be clinically or Can’t be clinically or pathologicaly any pathologicaly any other diseaseother disease

PremalignantPremalignant Etiologic factors: Etiologic factors:

tobacco ,alcohol ,catobacco ,alcohol ,candida ,electrogalvanindida ,electrogalvanic react.c react.

mostly on buccal mostly on buccal mucosa ,lower mucosa ,lower lip ,gingiva.lip ,gingiva.

Less common on Less common on palate, retromolar palate, retromolar area ,floor of mouth & area ,floor of mouth & tonguetongue

90% of dysplasia in 90% of dysplasia in tongue & floor of tongue & floor of mouth lesionsmouth lesions

Idiopathic (true) Idiopathic (true) leukoplakialeukoplakia::

1.1. Homogenous Homogenous Leukoplakia:Leukoplakia:

Well defined patchWell defined patch Elevated ,fissured Elevated ,fissured

,wrinkled ,wrinkled Palpation: Palpation:

leathery or dry leathery or dry cracked mud like cracked mud like


2.2. Speckled Speckled Leukoplakia:Leukoplakia:

Mixed red & whiteMixed red & white Keratotic nodules Keratotic nodules

on atrophic red on atrophic red basebase

High malignant High malignant transformationtransformation


3.3. Verrocous Verrocous leukoplakia:leukoplakia:

Thick with Thick with papillary surfacepapillary surface

Heavily keratinizedHeavily keratinized

In older ptIn older pt


4.4. Proliferative Proliferative Verrocous Verrocous leukoplakia:leukoplakia:

Extensive papilary Extensive papilary plaqueplaque

Involve multiple Involve multiple mucosal sitesmucosal sites

Transform to sq. Transform to sq. cell carcinomacell carcinoma

DiagnosisDiagnosis: :

Clinically:Clinically: CanCannotnot be stripped or rubbed off be stripped or rubbed off

LossLoss of elasticity (Stretching) & of elasticity (Stretching) & pliability (bending)pliability (bending)

DiagnosisDiagnosis: :

Tissue BiopsyTissue Biopsy Toluidine blue stainingToluidine blue staining: stain : stain

dysplastic & malignant cells , resist dysplastic & malignant cells , resist washing awaywashing away

Cytobrush techniqueCytobrush technique: firm bristle : firm bristle brush to obtain cells from full brush to obtain cells from full thickness of epith. For cytologic thickness of epith. For cytologic examination examination



ErythroplakiaErythroplakia::

Red bright velvety Red bright velvety areaarea

Tongue ,floor of Tongue ,floor of mouth , soft mouth , soft palate ,ant.tonsillar palate ,ant.tonsillar pillarspillars

AsymptomaticAsymptomatic High malignant High malignant

transformationtransformation

ErythroplakiaErythroplakia::

http://screening.iarc.fr/atlasoral_detail.php?flag=0&lang=1&Id=A3000010&cat=A3&PHPSESSID=ac3a89219d2a7c7ccc0222941a124f88



Lichen PlanusLichen Planus::

1.1. Skin lesionSkin lesion:: pruritic, polygonal, pruritic, polygonal,

papules & plaquepapules & plaque 2-4mm with 2-4mm with

angular border, angular border, violaceous colorviolaceous color

SymmetricallySymmetrically Flexor surfaces of Flexor surfaces of

wrists, legs, trunkwrists, legs, trunk Koebners Koebners

phenomenonphenomenon

Lichen PlanusLichen Planus::

2.2. Nail lesions:Nail lesions: In 10% of casesIn 10% of cases Nail bed Nail bed

discolorationdiscoloration Lateral thinningLateral thinning Complete loss of Complete loss of

nail matrixnail matrix Scarring of Scarring of

proximal nail foldproximal nail fold

Lichen Planus (Lichen Planus (reticularreticular))

Slightly elevated lines Slightly elevated lines “wickham’s striae”“wickham’s striae”

Annular lesionAnnular lesion Eleveted papulesEleveted papules Large plaqueLarge plaque Asymptomatic – Asymptomatic –

roughnessroughness Buccal mucosa, Buccal mucosa,

dorsum of tongue, dorsum of tongue, gingiva gingiva

Lichen planusLichen planus ((papular &reticularpapular &reticular))

Hypertrophic form

Lichen Planus(Lichen Planus(atrophicatrophic))

Inflammed areas of Inflammed areas of oral mucosaoral mucosa

Covered by thinned Covered by thinned red epitheliumred epithelium

symptomaticsymptomatic

Lichen Planus(Lichen Planus(erosiveerosive))

Complication of Complication of atrophic typeatrophic type

Thin epithelium Thin epithelium become abraded or become abraded or ulceratedulcerated

Symptomatic: mild Symptomatic: mild burning – severe burning – severe painpain

Erosive lichen Planus

Lichen Planus(Lichen Planus(bullousbullous))

ImmunoflourescentImmunoflourescent::

Shaggy band of Shaggy band of fibrinogen at B.M fibrinogen at B.M zonezone

IgM in dermal IgM in dermal papilla in peribasal papilla in peribasal areaarea

Lichenoid reactionLichenoid reaction::

L.P like lesionsL.P like lesions

Due to systemic Due to systemic drug treatmentdrug treatment



Lupus erythematosus:Lupus erythematosus:

Autoimmune C.T Autoimmune C.T diseasedisease

Forms:Forms:1.1. Discoid (DLE)Discoid (DLE)2.2. Systemic (SLE)Systemic (SLE)D.L.ED.L.E: : cheeks, nose bridge, cheeks, nose bridge,

ears, side of neck & ears, side of neck & scalp scalp

Bilaterally not Bilaterally not necessarily necessarily symmetricalsymmetrical

Lupus erythematosusLupus erythematosus::

Butterfly rashButterfly rash Adherent scales on Adherent scales on

removal, its removal, its undersurface undersurface shows horny plugs shows horny plugs that occupied that occupied dilated sebaceous dilated sebaceous canalscanals

Tin-tack signTin-tack sign


S.L.E:S.L.E: Cutaneous erythema Cutaneous erythema

especially on light especially on light exposed areasexposed areas

Butterfly rash Butterfly rash Facial edema Facial edema PhotosensitivityPhotosensitivity Chronic urticariaChronic urticaria Non scaring alopeciaNon scaring alopecia


Oral lesion:Oral lesion: In 20% of SLE , more In 20% of SLE , more

common in DLEcommon in DLE White striated, White striated,

atrophic or erosive atrophic or erosive areasareas

Variable patterns of Variable patterns of white & red areas white & red areas



MiscellaneousMiscellaneousOral submucous fibrosisOral submucous fibrosis::

Slowly progressive Slowly progressive chronic fibrotic chronic fibrotic diseasedisease

premalignantpremalignant Fibroelastic changes Fibroelastic changes

& inflammation of & inflammation of mucosamucosa

Inability to open Inability to open mouth, swallow, mouth, swallow, speakspeak

Oral submucous fibrosisOral submucous fibrosis::

Fibrosis by Fibrosis by proliferation of proliferation of fibroblasts, collagen fibroblasts, collagen synthesis, decrease synthesis, decrease collagenase collagenase productionproduction

Due to nutritional & Due to nutritional & vitamin deficiency, vitamin deficiency, hypersensitivity to hypersensitivity to chili pepper, chili pepper, chewing tobacco chewing tobacco

Oral submucous fibrosisOral submucous fibrosis::

Clinically:Clinically: Burning sensationBurning sensation Vesicles & ulcerationVesicles & ulceration Excessive salivation or xerostomiaExcessive salivation or xerostomia Altered taste sensationAltered taste sensation Stiffness of mucosaStiffness of mucosa Mucosa is blanched & opaqueMucosa is blanched & opaque Buccal mucosa, soft palate, pharynx, Buccal mucosa, soft palate, pharynx,

lip, tongue lip, tongue

Geographic tongueGeographic tongue

FordyceFordyce’’s granuless granules

Linea Alba Linea Alba

Health & Medicine

White lesions(collection)