Considerations on the diagnosis of oral psoriasis: A case report

MIGLIARI DA, PENHA SS, MARQUES MM, MATTHEWS RW. CONSIDERATIONS ON THE DIAGNOSIS OF ORAL PSORIASIS: A CASE REPORT. MED ORAL 2004;9:300-3.

ABSTRACT

This paper discusses the difficulties in making a definitive diagnosis of oral psoriasis based upon clinical and histological evidence only. A young black male presented with multiple lesions showing erosions, fissures, and yellowish scales on the vermilion borders of both lips. He also had erythematous-erosive areas on the gingivae, a fissured tongue showing greyish areas on its ventral surface, whitish lesions and longitudinal sulci in the hard palate with lacelike lesions on the soft palate. Biopsies from the lower lip, gingiva and soft palate showed hyperkera-tosis, spongiosis, acanthosis, and elongation of rete ridges. In addition, collections intraepithelial micro-abscesses of Munro were observed. These findings are consistent with oral psoriasis. Typical cutaneous lesions and a family history of psoriasis were absent.

Key words: Diagnosis, oral lesions, oral psoriasiform lesions, psoriasis

INTRODUCTION

Psoriasis is a common skin disease that affects men and women equally, being more prevalent in caucasians with fifty percent of cases appearing before the second decade of life (1-4). The aetiology of the disease is unknown but a strong hereditary component is implicated (4).

The existence of true psoriatic lesions of the oral mucosa is disputed. Problems with the diagnosis of oral psoriasis arise from the fact that no distinction can be made on histological grounds between oral psoriasis and other oral diseases such as geographic tongue, geographic stomatitis, and the oral lesions of Reiter's syndrome (5-7). In addition, there is no consensus as to what can be described as a true lesion of oral psoriasis (1,4,7,8). Despite these difficulties, there is some agreement among authors that oral psoriasis, although rare, does occur and the diagnosis is best made when the clinical course of the oral lesions parallels that of skin lesions and is supported by histological examination (7-10).

The English-language literature reports only 9 cases of psoriasis presenting exclusively oral lesions (2,9,11-15). We report a case that presented with multiple oral lesions showing histological features of psoriasis but no family history of the condition or concurrent skin lesions.

CASE REPORT

A 13-year-old black male was referred to the Oral Medicine Clinic, Division of Dermatology of the Hospital das Clínicas, University of São Paulo School of Medicine, for evaluation of scales on his lips that had been present for 4 years. On examination the vermilion borders of the upper and lower lips were erythematous, fissured with yellowish adherent scales. The lower lip was slightly swollen (Fig. 1). Intraorally there was generalised oedema and erythema of the marginal and interproximal gingival mucosa, and areas of erosion on the attached gingiva. Oral hygiene was poor. The tongue was fissured and presented greyish areas on its ventral surface. The hard palate had a whitish surface associated with narrow longitudinal sulci and the soft palate presented white lesions displaying a lacelike/circinate pattern (Fig.2). Skin examination revealed some small papular areas on the upper thighs and lower trunk. All of the lesions were symptomless. His medical, social and family histories were unremarkable. The patient was a non-smoker.

The patient's blood count was normal and serological tests for syphilis were negative. Biopsies from the vermilion border of the lower lip, the soft palate, gingiva and thigh were performed. Histologically, the lip and oral mucosal tissues showed a pattern consistent with psoriasis (Fig.3). The thigh skin biopsy showed only hyperkeratosis and acanthosis without any features of psoriasis. The labial, palatal and gingival biopsies showed hyperplasia of the epithelium and acanthosis. Neighbouring rete ridges were seen to coalesce at their bases with elongation, oedema and the presence of dilated tortuous capillaries surrounded by a dense plasma cell infiltrate. Epithelial spongiosis was observed and some areas showed acanthosis. Micro-abscesses of Munro within the parakeratotic epithelial layer and the occasional small spongiform pustules were present. No granulomas were observed. Periodic acid-Schiff (PAS) stain for fungal hyphae was uniformly negative.

A programme of oral hygiene improvement was commenced. Initial treatments with Vitamin A derivatives and topical steroids proved ineffective and therefore withdrawn. As the patient experienced no discomfort from the lesions, no further medication was considered necessary. The patient was reviewed regularly for 3 years. During this period the clinical aspects of the oral mucosa lesions remained unchanged. Improvement of the appearance of his lip lesions was achieved with a cosmetic moisturising cream. His skin lesions remained unchanged and there were no signs of cutaneous psoriasis over this period.

DISCUSSION

Many authors propose strict criteria for the diagnosis of oral psoriasis. The clinical course of the oral lesions should parallel that of the skin lesions (7,9,16). Additionally, a positive family history and HLA typing have also been considered of great importance in supporting a diagnosis of oral psoriasis (2,9,14,15). The HLA antigens most frequently associated with psoriasis are B13, B17, B37, Cw4 and Cw6 (3,4,14,16). HLA typing of this patient was not possible.

Other diseases such as geographic tongue, geographic stomatitis and Reiter's syndrome, histologically similar to psoriasis must be excluded (6,14,16). In this case Reiter's syndrome was excluded as the patient had none of the other triad of symptoms associated with this syndrome. The oral biopsies showed a psoriasiform pattern but the clinical appearance of the lesions did not match that of geographic stomatitis. Oral candidosis and secondary syphilis, that can resemble psoriasis, were also excluded. No fungal hyphae were found. The lip lesions and fissured tongue resembled Melkersson-Rosenthal syndrome but this was not supported histologically. The clinical and histological findings of this case strongly suggested a diagnosis of oral psoriasis. Weighing against this diagnosis, however, are the absence of skin lesions, the lack of a family history of psoriasis and the absence of HLA typing. Of the 9 cases reported in the literature presenting oral psoriasis without cutaneous involvement, only 2 of them [14,15] fulfilled four of the five aspects of the diagnostic criteria - namely histopathology, family history, HLA type and exclusion of histologically similar conditions.

CONCLUSIONS

Our case demonstrates the difficulties involved in making a diagnosis of psoriasis based upon exclusive oral mucosa and lip lesions. The histological examination of three different oral sites all showed features of psoriasis, no candidosis and other clinical aspects ruled out Reiter's syndrome, geographic tongue and geographic stomatitis. Our conclusion is that this a case of oral psoriasis with no identified family history and cutaneous involvement limited to the vermillion border of the lips.

Aknowledgements

We would like to thank Dr. Myrian N. Sotto, Medical Pathologist and Associate Professor of Dermatology of Hospital das Clínicas, University of São Paulo School of Medicine, for her kind assistance with the histologic material. We also acknowledge the assistance of Dr John Eveson, Reader in Oral Pathology, University of Bristol Dental School, UK, for his evaluation of the biopsy specimens.

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