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Oral & Dental Health

Hairy Leukoplakia (Oral)

A benign, asymptomatic white lesion occurring on the lateral borders of the tongue, strongly associated with Epstein-Barr Virus (EBV) infection in the context of immunosuppression, particularly HIV/AIDS.

Also known as: Oral Hairy Leukoplakia, OHL

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Referral and warning signs

When to refer

Referral usually not needed for typical OHL. Refer to Oral Medicine Specialist or Physician if: Diagnosis is uncertain. Lesion is atypical in appearance or location. Patient desires treatment for cosmetic reasons. Assessment of underlying immunosuppression needed.

Red flags

  • Lesion not on lateral tongue border.
  • Associated pain, ulceration, or induration (suggests different diagnosis).
  • Rapid change in appearance.

Signs and symptoms

  • White, corrugated or 'hairy' appearing patches or plaques.
  • Almost exclusively located on the lateral borders of the tongue (usually bilateral, can be unilateral).
  • Lesions are adherent (cannot be wiped off).
  • Usually asymptomatic (no pain or soreness).
  • May vary in size and thickness.
  • Surface may appear vertically ribbed or shaggy.

Risk factors

  • HIV infection / AIDS (especially with moderate to severe immunosuppression - lower CD4 counts).
  • Other causes of immunosuppression (e.g., post-transplant, long-term steroids).
  • Epstein-Barr Virus (EBV) infection (ubiquitous, but reactivation in immunosuppression causes OHL).

Diagnosis

Clinical assessment

Diagnosis is usually clinical, based on characteristic appearance (white, corrugated, adherent lesion) and typical location (lateral tongue borders) in an at-risk patient (HIV+ or immunosuppressed).

Differential diagnosis

  • Frictional keratosis / Traumatic keratosis (related to sharp tooth/denture, flatter).
  • Candidiasis (Pseudomembranous type wipes off; Hyperplastic type doesn't wipe off but looks different).
  • Lichen Planus (may have reticular pattern, often bilateral buccal mucosa too).
  • Leukoplakia (idiopathic or tobacco-related - potentially pre-malignant, usually flatter).
  • Squamous Cell Carcinoma (rarely presents this way, usually ulcerated/indurated).

Investigations

  • Clinical appearance usually sufficient.
  • Biopsy: Rarely needed unless appearance is atypical or diagnosis uncertain (to rule out dysplasia/malignancy). Shows characteristic histology (hyperkeratosis, acanthosis, koilocyte-like cells, EBV presence).
  • HIV testing (if status unknown).

Diagnostic criteria

Clinical diagnosis based on characteristic appearance and location in an appropriate clinical context (immunosuppression).

Management

Non-pharmacological management

  • No treatment required for the lesion itself as it is benign and asymptomatic.
  • Initiation or Optimization of Antiretroviral Therapy (ART): For HIV-positive individuals, ART often leads to spontaneous regression or resolution of OHL as immune function improves.

Pharmacological treatment

  • Specific treatment usually not necessary.
  • High-dose systemic antivirals (Acyclovir, Valacyclovir, Famciclovir) can cause temporary regression but lesions often recur upon cessation - generally NOT indicated.
  • Topical Podophyllin resin 25% applied weekly (UCG suggestion - specialist use, potential irritation).
  • Topical Retinoids (Tretinoin) - specialist use.

Monitoring

Monitor lesion appearance. Monitor HIV status and response to ART.

Complications

  • None directly from the lesion itself.
  • May cause mild cosmetic concern.
  • Its presence indicates significant immunosuppression (in HIV context) and may predict progression to AIDS if ART not initiated.

Prevention

  • Effective Antiretroviral Therapy (ART) for HIV prevents development or leads to resolution.

Patient education

  • Reassurance about the benign nature of the lesion (not cancer, not pre-cancerous).
  • Explanation of the link with EBV and immunosuppression (especially HIV).
  • Indicates the need to check/monitor immune status (CD4 count).
  • Importance of ART adherence if HIV positive (lesion often resolves with treatment).
  • No specific treatment usually needed for the lesion itself.

Uganda-specific notes

OHL is a common oral manifestation of HIV/AIDS and serves as a clinical marker for immunosuppression. Its presence should prompt HIV testing if status unknown and assessment of immune status (CD4) if known HIV+. Resolution with ART is typical.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 23, Section 23.3.4

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 7 (HIV Care - OIs)

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