Oral hairy leukoplakia
Oral hairy leukoplakia is a benign, EBV-driven hyperplasia of the lateral tongue that occurs in HIV and other immunosuppressed hosts and is diagnosed at the bedside by its single defining feature: it does not scrape off, unlike oral candidiasis. It requires no treatment for the lesion itself, typically resolves as antiretroviral therapy restores immune function, and carries no malignant potential.
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What this article covers
- Overview
Oral hairy leukoplakia is a benign, EBV-driven hyperplasia of the lateral tongue epithelium that appears when Epstein-Barr virus, latent in nearly all adults, begins actively replicating in oral…
- Epidemiology
Occurs predominantly in patients with untreated or advanced HIV infection, classically with CD4 counts below 500/mcL, and becomes more frequent as the CD4 count falls further.
- Risk factors
Untreated or poorly controlled HIV infection with a low CD4 count is the dominant risk factor.
- Pathophysiology
Epstein-Barr virus (HHV-4) establishes lifelong latency in B cells after primary infection, and serologic evidence of prior EBV infection is present in almost all adults.
- Clinical features
The defining and diagnostic combination is a white, corrugated or "hairy," firmly adherent plaque on the lateral tongue that cannot be scraped off with a tongue depressor or gauze, in a patient with…
- Differential diagnosis
Oropharyngeal candidiasis (thrush): the most important mimic and most common cause of confusion; white plaques that DO scrape off with a tongue depressor, revealing an erythematous base; seen with…
- Diagnosis
Oral hairy leukoplakia is a clinical diagnosis, established by the characteristic appearance (white, corrugated, adherent) and location (lateral tongue) together with the finding that the lesion does…
- Management
The initial step is to recognize that the lesion itself is asymptomatic and requires no direct treatment, since it causes no functional impairment and, unlike leukoplakia elsewhere in the mouth, has no malignant potential to monitor.
- Complications
Diagnostic delay from mistaking the lesion for oral candidiasis, leading to ineffective antifungal treatment and a missed opportunity to test for or address underlying HIV infection.
- Prognosis
Excellent: the lesion is benign and self-limited relative to the course of the underlying immunosuppression, with no risk of malignant transformation, in direct contrast to idiopathic oral leukoplakia.
- Prevention
Start antiretroviral therapy in every HIV-positive patient regardless of CD4 count, ideally within 2 weeks of diagnosis, since restoring cell-mediated immunity is the most effective way to prevent both initial development and recurrence.
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