Psoriasis of the tongue
Guido C. LIER1, Ulrich MROWIETZ2, Mona WOLFART3, Patrick H. WARNKE1, Jo¨rg WILTFANG1, Ingo N. G. SPRINGER1
1Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Dr. J. Wiltfang), University of Kiel, Germany;
2Department of Dermatology, Venereology and Allergology (Head: Prof. Dr. Th. Schwarz), University of Kiel, Germany;3Department of Prosthodontics, Propaedeutics and Dental Materials (Head: Prof. Dr. M. Kern), University of Kiel, Germany
SUMMARY. Introduction: Psoriasis is a common, chronic dermatologic disease. Cases affecting the oral mucous membranes are rarely reported in the international literature, in particular tongue lesions are hardly ever doc- umented. Material and methods: This article presents a 61 year old patient with persistent whitish lesion on his tongue. Biopsy specimens from mid surface and tip of the tongue were taken. Histopathologic sections were stained with haematoxylineeosin (HeE) as well as with Periodic acid-Schiff (PAS) and examined by light microscopy. Results: Tongue lesions showing epithelial hyperplasia, parakeratosis, long papillae, neutrophils and microabscesses of Munro. Conclusions: The reported case suggests that the clinical and histological appearances of the lesions are consistent with mucosal psoriasis. Ó 2008 European Association for Cranio-Maxillofacial Surgery
Keywords: mucous membranes, oral psoriasis, psoriasis of the tongue
INTRODUCTION
Psoriasis is a common, chronic dermatologic disease with an incidence of about 2% in the western population. Usu- ally it develops first in young adults and may be followed by periods of exacerbation and remission (Elder et al., 2001). The aetiology of the disease is unknown, but a mul- tifactorial disease with heritable and exogenous factors is likely (Elder et al., 2001). Various triggers, such as stress, streptococcal infections, and certain medications (beta- blockers, antimalarials, lithium) are known to activate new episodes (Tsankov et al., 2000). The pathogenesis of psoriasis is characterized by an approximately 7-fold increase in turnover time of the epithelial cells (Christo- phers and Mrowietz, 2003). An increased influx of den- dritic cells from the peripheral blood in psoriatic skin lesions, regulated by proteinaceous chemotaxins, seems to be of major importance in the pathogenesis of psoriasis (Christophers and Mrowietz, 2003; Lebwohl, 2003).
The most common form of the disease, psoriasis vul- garis, appears clinically as cutaneous erythematous pla- ques covered by white or silvery scales. Their size varies from only a few pinpoint lesions to large plaques.
These skin lesions are characteristically found on the scalp and extensor areas of extremities. The histological appearance of epithelial changes varies with the age and activity of the lesions. Parakeratosis, acanthosis and spongiosis with budding of the tips of the rete ridges and thinning of the suprapapillary plate are usually found. Polymorphonuclear leucocytes migrate through the epithelium with the formation of intraepithelial mi- croabscesses (Munro abscesses). Microabscesses are
characteristic of psoriasis, but not specific for the disease, nor always present. Within the dermis, at the tips of the connective tissue papillae, the capillaries show dilatation and tortuosity and a mixed inflammatory cell infiltrate is commonly seen (Lever, 1967; Montgomery, 1967; Chris- tophers and Mrowietz, 2003).
The occurrence of true psoriatic lesions on mucous membranes is disputed. For many years it has been claimed that the disease does not affect the oral mucosa.
Today it is thought that involvement of the oral cavity is rare but does exist.Oppenheim (1903)was the first to de- scribe oral psoriasis in a biopsy after histological exam- ination. In a review of English-language and European non-English literature Younai and Phelan (1997) only identified 57 cases of oral psoriasis. Since then seven new cases have been reported, bringing the total to 64 cases of the condition described in the literature (Robin- son et al., 1996; Younai and Phelan, 1997; Brice and Da- nesh-Meyer, 2000; Richardson et al., 2000;
Ariyawardana et al., 2004; Migliari et al., 2004; De Biase et al., 2005). The reports described a number of oral locations, such as lips, buccal mucosa, gingivae, pal- ate, tongue and floor of the mouth. Of these, only 11 cases since 1903 have demonstrated characteristic, true psoriatic lesions on the tongue and in five of these no other non-mucosal manifestation of psoriasis was present (Younai and Phelan, 1997; De Biase et al., 2005). Clin- ically of the cases reviewed byYounai and Phelan, 44%
of patients presented with white, 24% with erythema- tous, and 13% with mixed red and white intraoral le- sions. The remaining lesions appeared ulcerative, vesicular, pustular, or indurated.
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Journal of Cranio-Maxillofacial Surgery (2009) 37, 51e53 Ó 2008 European Association for Cranio-Maxillofacial Surgery
doi:10.1016/j.jcms.2008.07.003, available online athttp://www.sciencedirect.com
The histopathological findings in oral mucous mem- branes are assumed to be similar to those found in skin lesions. Epithelial parakeratosis, elongated rete ridges and the presence of an inflammatory infiltrate of the up- per dermis were described in most cases (Younai and Phelan, 1997).
We present a case of a lesion of the tongue with histo- logical features of psoriasis in a patient with previously diagnosed concurrent skin lesions.
CASE REPORT
A 61 year old Caucasian man presented to the Prostho- dontics Clinic on routine oral examination a persistent white lesion on his tongue was evident. He was referred to the Department of Oral and Maxillofacial Surgery, University Hospital Schleswig-Holstein, Campus Kiel.
Skin examination showed psoriatic lesions on the right leg and face (Figs. 1 and 2).
The patient’s medical history did not reveal any other known disease or allergies nor was he taking any medi- cations. He head psoriasis vulgaris which diagnosed at the age of 45 at the Department of Dermatology, Vene- reology and Allergology, University Hospital Schles- wig-Holstein, Campus Kiel.
The patient was partially edentulous; the tongue was oedematous with a fissured dorsum covered by a thin white layer. The white ‘‘fur’’ observed was adherent and did not rub off. Erythematous areas were evident lat- erally and at the tip of the tongue (Fig. 3). The remaining oral mucous membranes were not involved. Biopsy spec- imens from mid surface and tip of the tongue were taken.
Histopathological sections were stained with haema- toxylineeosin (HeE) as well as with Periodic acid-Schiff (PAS) and examined by light microscopy. The biopsies showed surface parakeratosis, acanthosis, psoriaform hyperplasia, long papillae and a superficial inflammatory infiltrate. Small intraepithelial microabscesses (Munro) and superficial erosions were observed (Figs. 4 and 5).
PAS stain for fungal hyphae was negative throughout.
These findings were reported as being consistent with mu- cosal psoriasis.
DISCUSSION
Oral lesions of psoriasis have been described in all re- gions of the oral mucous membranes (Robinson et al., 1996; Younai and Phelan, 1997; Brice and Danesh- Meyer, 2000; Richardson et al., 2000; Ariyawardana
Fig. 1 eLesions on the patient’s forehead at the time of presentation with psoriasis of the tongue. A clear distinction between facial psoriasis and seborrheic dermatitis cannot be made.
Fig. 2 eLesions on the patient’s nose and cheeks at the time of presentation with psoriasis of the tongue. A clear distinction between facial psoriasis and seborrheic dermatitis cannot be made.
Fig. 3 eIntraoral appearance: psoriatic mixed white and red lesion at the dorsum and tip of the tongue.
Fig. 4 eTongue lesions exhibiting epithelial hyperplasia, parakeratosis, long papillae, neutrophils and microabscesses of Munro (magnification:
200).
52 Journal of Cranio-Maxillofacial Surgery
et al., 2004;Migliari et al., 2004; De Biase et al., 2005).
Variation of location, character, and colour may contrib- ute to difficulties in the clinical diagnosis of the disease (Younai and Phelan, 1997). The differentiation from other oral diseases such as geographic tongue, fissured tongue, oral candidosis and the oral lesions of Reiter’s syndrome may be subtle. The diagnosis is best made when the clinical features of oral lesions parallels that of skin lesions and is supported by histological investiga- tion (Weathers et al., 1974; Younai and Phelan, 1997;
Bruce and Rogers, 2003). In the present case, Reiter’s syndrome could be excluded as the patient exhibited none of the other symptoms of the triad (conjunctivitis, urethritis, arthritis) associated with this disease. Oral can- didosis was ruled out as PAS stain for fungal hyphae was negative. The clinical and histological appearances of the lesions did not match those of geographic or fissured tongue. Oral lichen planus and lichenoid reactions have a different clinical and histological appearances (Dun- sche et al., 2003). Above all a malignant disease should be ruled out particularly with regard to the increasing number of head and neck cancer cases in the last 15 years (Lung et al., 2007).
CONCLUSION
The examination of this patient presented excluded clin- ically and histologically similar conditions and strongly suggested a diagnosis of oral psoriasis. However at the time of presentation mild psoriatic lesions were only present on the face and these clinically also resembled seborrheic dermatitis. Nevertheless, psoriasis with typical
erythemato-squamous plaques had been diagnosed by dermatologists previously.
References
Ariyawardana A, Tilakaratne WM, Ranasinghe AW, Dissanayake M:
Oral psoriasis in an 11-year-old child: a case report. Int J Paediatr Dent 14: 141e145, 2004
Brice DM, Danesh-Meyer MJ: Oral lesions in patients with psoriasis:
clinical presentation and management. J Periodontol 71: 1896e 1903, 2000
Bruce AJ, Rogers 3rd RS: Oral psoriasis. Dermatol Clin 21: 99e104, 2003
Christophers E, Mrowietz U: Psoriasis. In: Freedberg IM, Eisen AZ, Wolff K (eds), Dermatology in general medicine, New York:
McGraw-Hill, 407e427, 2003
De Biase A, Guerra F, Polimeni A, Ottolenghi L, Pezza M, Richetta AG: Psoriasis of the dorsal surface of the tongue. Minerva Stomatol 54: 525e529, 2005
Dunsche A, Ka¨stel I, Terheyden H, Springer IN, Christophers E, Brasch J: Oral lichenoid reactions associated with amalgam:
improvement after amalgam removal. Br J Dermatol 148: 70e76, 2003
Elder JT, Nair RP, Henseler T, Jenisch S, Stuart P, Chia N, Christophers E, Voorhees JJ: The genetics of psoriasis 2001: the odyssey continues. Arch Dermatol 137: 1447e1454, 2001 Lebwohl M: Psoriasis. Lancet 361: 1197e1204, 2003
Lever WF: Histopathology of skin, Philadelphia: J.B. Lippincott Company, p. 141e144, 1967
Lung T, Tasxcau OC, Almasxan HA, Muresxan O: Head and neck cancer, epidemiology and histological aspects e part 1: a decade’s results 1993e2002. J Craniomaxillofac Surg 35: 120e125, 2007 Migliari DA, Penha SS, Marques MM, Matthews RW: Considerations
on the diagnosis of oral psoriasis: a case report. Med Oral 9: 300e 303, 2004
Montgomery H: Dermatopathology. New York: Harper & Row, p.
309e352, 1967
Oppenheim M: Psoriasis mucosae oris. Monatsschr Prakt Dermatol 37:
481, 1903 [in German]
Richardson LJ, Kratochvil FJ, Zieper MB: Unusual palatal presentation of oral psoriasis. J Can Dent Assoc 66: 80e82, 2000
Robinson CM, DiBiase AT, Leigh IM, Williams DM, Thornhill MH:
Oral psoriasis. Br J Dermatol 134: 347e349, 1996 Tsankov N, Angelova I, Kazandjieva J: Drug-induced psoriasis.
Recognition and management. Am J Clin Dermatol 1: 159e165, 2000
Weathers DR, Baker G, Archard HO, Burkes Jr EJ: Psoriasiform lesions of the oral mucosa (with emphasis on ‘‘ectopic geographic tongue’’). Oral Surg Oral Med Oral Pathol 37: 872e888, 1974 Younai FS, Phelan JA: Oral mucositis with features of psoriasis: report
of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 84: 61e67, 1997
Priv. Doz. Dr. Dr. Ingo N. G. SPRINGER University of Kiel
Arnold-Heller-Str. 16 D-24105 Kiel, Germany Tel./Fax: +49 431 5972838 E-mail:springer@mkg.uni-kiel.de Paper received 14 September 2007 Accepted 21 July 2008
Fig. 5 eTongue lesions exhibiting epithelial hyperplasia, parakeratosis, long papillae, neutrophils and microabscesses of Munro (magnification:
400).
Psoriasis of the tongue 53
