Hairy Leukoplakia

Oral hairy Leukoplakia , which presents as a non-movable, corrugated or "hairy" white lesion on the lateral margins of the tongue occurs in all risk groups for HIV infections, although less commonly in children than in adult.
It occurs in about 20% of persons with asymptomatic HIV infection & becomes more common as the CD4+ T cell count falls.
Etiology

• Exact etiology is not known but Epstein-Barr virus has identified in these lesions.
• One hypothesis is that basal epithelial cells of lateral margin of tongue normally harbors EBV in majority of adult population,who are EBV sero-positive  & carrier of that disease. It is found primarily in homosexual male.
• Direct infection of Langerhans' cell due to HIV induced loss of factor essential for their integrity & function,permit reactivation of EBL with frequent epithelial hyperplasia.

Clinical Features

• Site-Unique & significant lesion which primarily occurs unilaterally or bilaterally on the lateral border of tongue. It can also occur on dorsum of the tongue, buccal mucosa, floor of mouth, retromolar areas & soft palate.
• Appearance-there is characteristic corrugated and white appearance. It does not rub off and may resemble the keratotic lesion.
• Surface- the surface is irregular and may have resembling hairs. occasionally, however, some areas may be smooth and flat. Lesions occur most commonly on the lateral margins of the tongue and may spread to cover the entire dorsal surface.
• Spread-they may spread downward on to the ventral surface of the tongue ,where they usually appear flat.
• sometimes white lesion satisfies many criteria for diagnosis of hairy Leukoplakia, but if EBV not present this is called pseudohairy Leukoplakia .
• Presence of hairy Leukoplakia is fairly indicator of HIV prosensitivity and is predictor of deficiency immunocompetence.

Histopathological features

• histologically lesion shows hyperkeratosis,acanthosis,ballooning cells,epithelial cells contain Epstein-Barr virus & no or minimum inflammation.
• Immunochemistry tissue in situ  hybridization, non-invasive tissue in situ hybridization , or electron microscopy does demonstrate of Epstein-Barr virus.
• The lesion of Leukoplakia consists of Langerhans cells.

Management

• Hairy Leukoplakia is usually asymptomatic & does not require treatment.hairy Leukoplakia is almost always a manifestation of HIV infection & clinicians should arrange evaluation of HIV disease & appropriate treatment  for patients with hairy leukoplakia Doses of acyclovir-2.5 to 3 mg per day for 2-3 weeks usually eliminates hairy leukoplakia but the lesion usually recurs with cessation of treatment.
• Desciclovir,phosphonoformate, Retin A & podophyllin resin have also been found effective in oral hairy leukoplakia, although lesion tend to reoccur with in few months.
• Occasionally Candida albicans may be found in hairy leukoplakia .treatment consists of antifungal medications like:-

1. Topical agent- clotrimazole 10 mg 5 times a day
2. Nystatin 10000 units/gm 5 times a day
3. Systemically:-Ketoconazole 200mg BD aday.acyclovir,azidothymidine & retinoic acid, podophyllin resin.