Oral hairy leukoplakia in an immunocompetent patient treated with topical steroids for oral lichen planus

Abstract

<h3>Objectives</h3> Oral Hairy Leukoplakia (OHL) is an Epstein-Barr Virus (EBV)-related lesion of the oral mucosa, most commonly affecting immunocompromised patients. Although HIV-infection appears to be the most frequent pre- disposing factor, OHL cases have been reported in patients with other causes of systemic or even local immuno- suppression. Herein, we present a case of OHL arising in an HIV-negative immunocompetent patient treated with topical steroids for Oral Lichen Planus (OLP). <h3>Findings</h3> A 62 years old male patient with biopsy-proven OLP presented for his regular follow-up. He was un- der treatment with topical steroids: fluocinonide (oral gel) and dexamethazone (oral solution). Clinical examina- tion revealed a white plaque of irregular surface involving the right lateral border of the tongue, which had not been noticed in the previous follow up appointment, 2 months ago. With a differential diagnosis of morsicatio linguarum, hypertrophic OLP and leukoplakia, an incisional biopsy was performed. Histopathologic examination revealed hyperkeratotic squamous epithelium with surface corrugations and the presence of "balloon cells" in the upper spinous layer, some of which exhibited nuclear beading in high power magnification. Immunohistochem- ical examination for EBV-LMP1 and in-situ hybridization for EBV were positive, establishing a diagnosis of OHL. Although no symptoms or signs of immunosuppression/HIV infection were present, the patient underwent blood examinations, including an HIV ELISA antibody test, which were within normal limits. In the absence of any in- dications of systemic causes, a diagnosis of OHL associated with local immunosuppression due to long-term use of topical corticosteroids was rendered. <h3>Conclusions</h3> OHL may be associated with different types of immunosuppression. In recent years, few cases of OHL developing in patients treated with topical steroids have been reported, the majority of which were linked to inhalers for pulmonary diseases. Topical steroid-induced immunosuppression in patients with oral mucocutaneous diseases should be considered as a possible, albeit unusual, cause of OHL.