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Painful white spots on a man’s tongue

Denise Rizzolo, PA-C, MS; Thomas A. Chiodo, DDS

Denise Rizzolo is a clinical assistant professor in the Seton Hall University PA program and is in private practice at the Care Station, Springfield, New Jersey. Thomas Chiodo is an oral maxillofacial surgeon in private practice in the New York area. They have indicated no relationships to disclose relating to the content of this article. Joe Monroe practices in the dermatology department of the Warren Clinic, Tulsa, Oklahoma, and is the founder and president of the Society of Dermatology Physician Assistants.

A 46-year-old man presents with mildly painful white spots on his tongue. He first felt pain 1 week earlier. The patient denies having hypertension, hypercholesterolemia, autoimmune disease, or diabetes and is not currently taking any prescription medications. The patient smokes 1 to 2 cigarettes per week and drinks 1 to 2 beers per week. His last physical examination was 9 months ago, and he cannot remember when he had his last dental examination.

On examination, white, slightly raised linear striae with a small erosion in the center were present on his tongue, and they remained unchanged when wiped with a cotton applicator (see Figure 1). A small erosion was found on the buccal mucosa. Both areas were mildly painful when manipulated.

The most likely diagnosis is

Idiopathic leukoplakia
Candidiasis
Lichen planus

DISCUSSION

The patient was referred to an oral and maxillofacial surgeon for further evaluation. A biopsy of the lesion revealed vacuolation of the basal cell layer with a band of lymphocytic infiltrate and clefting between the mucosa and underlying connecting tissue. There were an increased number of Langerhans cells and Civatte bodies. Direct immunofluorescence of the specimen was positive only for fibrin in the connective tissue layer. This combination of features indicates a diagnosis of lichen planus, a common chronic mucocutaneous disease that affects men and women equally.¹ Lichen planus can occur anywhere on the skin.

Oral lichen planus manifests several different ways. The reticular form—the most common type—appears as numerous interlacing keratotic lines or striae; it is generally asymptomatic but can cause mild symptoms. The plaque form is characterized by a white, slightly elevated, irregular hyperkeratotic patch and can cause mild pain. The erosive form manifests as erythematous mucosal inflammation, is extremely painful, and has an increased risk of becoming cancerous in severe longstanding cases.² Our patient had a combination of reticular and mild erosive lichen planus.

Idiopathic leukoplakia appears as white patches or plaques in the oral cavity that cannot be wiped off. Candidiasis, commonly known as thrush, appears as white, soft plaques or pseudomembranes on the buccal mucosa and tongue. The plaques can be removed with gauze and leave an erythematous or ulcerated, tender surface.

Treatment Currently, there is no specific treatment for lichen planus that is completely successful. Corticosteroids remain the cornerstone. Reticular and plaque forms can be managed with 0.05% fluocinonide gel, whereas the erosive form requires systemic corticosteroids. Periodic examinations are an important part of treatment. Because of the potential for malignant transformation, patients with erosive lichen planus should be monitored carefully and they should be advised to discontinue tobacco and alcohol use immediately.

REFERENCES

1. Regezi JA, Sciubba JJ, Jordan RCK. Oral Pathology: Clinical Pathologic Correlations, 4th ed. St. Louis, Mo: WB Saunders; 2003.

2. Fatahzadeh M, Rinaggio J, Chiodo T. Squamous cell carcinoma arising in an oral lichenoid lesion. J Am Dent Assoc. 2004;135(6):754-759.