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Erythroplakia



ERYTHROPLAKIA: CLINICAL FEATURES, HISTOPATHOLOGY AND TREATMENT

Author: Sanketh DS, MDS

INTRODUCTION

“Erythro” stands for red and “plakia” for patch. Erythroplakia, classified as a potentially malignant disorder, is a red patch that cannot be clinically diagnosed as any other disease. It has had numerous definitions over the years since it was first defined in 1971. Erythroplakia was defined by World Health Organization (WHO) in 1997 as “A fiery red patch that cannot be characterized clinically or pathologically as any other definable lesion”.

The definition of erythroplakia is unusual in that the diagnosis is one of exclusion of other red lesions rather than depending on a definable appearance of the lesion. To make it easier to understand, let’s say you have a patient with a suspicious red patch in the buccal mucosa. Since there are several other red lesions that look like erythroplakia, make sure it is not any other red lesion. Only after this, could you make a diagnosis of erythroplakia. Hence, it is a diagnosis of exclusion!

ETIOLOGY

The pathogenesis of erythroplakia is not fully understood; tobacco chewing and alcohol drinking have been implicated as strong risk factors for the development of erythroplakia. Candida albicans and Human papilloma virus (HPV) have been demonstrated in patients with erythroplakia, though their role with relation to this lesion is still not clear. There have also been reports where higher socio economic index, high income and education have shown to be associated with a decreased risk for oral erythroplakia and other oral premalignancies.

There are red lesions that may occur on the palate in individuals who may have a habit of reverse smoking. That is, the tobacco product is reverse smoked with the lit/burning end of the cigarette inside the oral cavity. This form of smoking is called reverse smoking and any red palatal change occurring as a result is not designated as erythroplakia but is called “reverse smoker’s palate”. These lesions are in fact classified as potentially malignant disorders.

CLINICAL FEATURES

Several large scale epidemiological studies have been conducted and the prevalence of erythroplakia has been speculated to range from 0.02% to 0.83%. Erythroplakia is considerably lesser in prevalence than leukoplakia. There is no specific gender predilection for erythroplakia and the older age group is usually affected. Erythroplakia has been reported in the sixth to seventh decade in the United States while studies conducted in India report a mean age group between 45 and 54.

The soft palate, floor of the mouth, buccal mucosa and ventral tongue are most often affected. Erythroplakic lesions are flat, red and velvety that may or may not have regular margins. The surface of the lesion is usually smooth and homogenous, but may also be granular or nodular with specs of white spots interspersed in the lesion. Such lesions may be called erythro-leukoplakia, leuko-erythroplakia, speckled leukoplakia or speckled erythrolakia. This has been a problem that has been addressed by pathologists and researchers. There has been much confusion in designating such “mixed red-white lesions” as all these terms can be interchangeably used to describe leukoplakia with red components or erythroplakia with white components. However, such a distinction may be subjective, academic and may not have much value, as mixed red-white lesions in general have to be treated with suspicion and patients have to be under a close follow up.

Erythroplakia has also been reported to be associated with or manifest adjacent lesions like leukoplakia and oral lichen planus.

HISTOPATHOLOGY

The histopathology for erythroplakia may vary from showing dysplastic features, carcinoma in situ or even invasive squamous cell carcinoma. Since most erythroplakias turn out to be either dysplastic or carcinomatous, it is generally agreed that all red lesions either homogenous or with white components have to be diagnosed and treated with caution unless proven otherwise.

DIFFERENTIAL DIAGNOSIS

The definition of erythroplakia makes it a diagnosis of exclusion. There are numerous other red lesions that have to be ruled out in order to make a diagnosis of erythroplakia. These are some important red lesions that have to be ruled out before making a diagnosis of erythroplakia:

Erythematous candidiasis
Denture stomatitis
Irritational mucositis
Oral lichen planus
Ectopic geographic tongue
Lupus erythematosus
Pemphigus
Pemphigoid
Kaposi sarcoma
Hemangioma

TREATMENT AND PROGNOSIS

Erythroplakia mandates effective treatment since they have a high risk for malignant transformation. Usually a biopsy of erythroplakia may dictate the treatment. Since most lesions show dysplasia or invasive carcinoma, a complete excision is the treatment of choice. And patients should be kept under a close follow up.

REFERENCES

Reichart PA, Philipsen HP. Oral erythroplakia–a review. Oral Oncol. 2005 Jul;41(6):551-61.

Villa A, Villa C, Abati S. Oral cancer and oral erythroplakia: an update and implication for clinicians. Aust Dent J. 2011 Sep;56(3):253-6.

Warnakulasuriya S. Clinical features and presentation of oral potentially malignant disorders. Oral Surg Oral Med Oral Pathol Oral Radiol. 2018 Jun;125(6):582-590.

van der Waal I. Potentially malignant disorders of the oral and oropharyngeal mucosa; terminology, classification and present concepts of management. Oral Oncol. 2009 Apr-May;45(4-5):317-23.

Neville BW, Damm DD, Allen CM, Chi A. Oral and Maxillofacial Pathology. South Asian ed. Elsevier; 2016.

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