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The lesion on this patient’s tongue really hurts

Sara Elder

Sara Elder is a student in the University of Oklahoma PA program, Oklahoma City. She has indicated no relationships to disclose relating to the content of this article.

CASE

A 56-year-old female was referred to dermatology by her primary care physician for evaluation of a moderately painful lesion on her tongue. On examination, a 2-cm, ovoid-shaped erosion was noted on the left lateral aspect of the tongue (see Figure 1). No significant lesions were found on the patient’s nails, buccal mucosa, face, trunk, or extremities. She denied any personal or family history of skin disorders and stated she was an otherwise healthy person. She denied the use of tobacco and alcohol. A biopsy of the lesion was taken.

WHAT IS THE MOST LIKELY DIAGNOSIS?

Squamous cell carcinoma
Oral candidiasis
Oral lichen planus
Psoriasis

DISCUSSION

The biopsy results revealed a diagnosis of lichen planus (LP). Patients frequently present with oral LP without corresponding cutaneous lesions. However, more than 70% of patients with cutaneous LP develop oral lesions as well.

Oral squamous cell carcinoma (SCC) is associated with chronic use of tobacco and alcohol. Our patient denied indulging in either of these habits. More compelling though, is the pain associated with her lesion. Patients with SCC seldom experience pain from their lesions.

Oral candidiasis rarely develops in children or adults when there is no underlying cause, such as immune suppression or antibiotic therapy. Candidia-sis is also unlikely to manifest as a single localized lesion on the tongue.

Psoriasis can appear in the mouth. Although psoriasis can be painful in that and other mucosal locations, the lesion is unlikely to ulcerate. Moreover, corroborative areas of psoriatic involvement would have been noted on the elbows, knees, scalp, or nails.

Treatment Topical corticosteroids are the mainstay of treatment for oral LP. Intralesional and/or systemic steroids may be required in difficult cases, especially when the condition manifests on mucosal surfaces. This patient was educated regarding her increased risk for oral cancer, which has been associated with undertreated LP lesions. She was informed that her lesion may persist or recur in spite of treatment. She was scheduled for a 1-month follow-up visit to monitor her progress.

Comment LP is a relatively common skin disorder that occurs in approximately 1% to 2% of the general population. The exact cause is unknown; however, some episodes appear to be triggered by an allergic or immune response. Acute episodes can persist for months to years, but usually they resolve within 2 years with symptomatic treatment for itching and rash. LP occurs equally in men and women, typically at age 30 to 70 years.

Most often, this rash manifests as reddish-purple, polyangular, pruritic papules or plaques. Lesions can appear anywhere on the body, but LP has a predilection for the volar wrists, ankles, back, feet, and penis, where the lesion tends to annularize. Histologic changes will show basal cell degradation, pigmentary incontinence, and a bandlike cellular infiltrate that often obliterates the dermo-epidermal interface. One in five patients with LP will have a second episode. JAAPA

Joe R. Monroe, PA-C, MPAS, department editor