Hairy Leukoplakia Differential Diagnoses

Updated: Aug 05, 2019
  • Author: James E Cade, DDS; Chief Editor: Jeff Burgess, DDS, MSD  more...
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DDx

Diagnostic Considerations

Also consider the following:

  • Geographic tongue
  • Frictional keratosis
  • Squamous cell carcinoma
  • Lichen planus
  • Tobacco-associated leukoplakia
  • Pseudo–hairy leukoplakia
  • Human papillomavirus (HPV)–induced neoplasia
  • Syphilitic mucous patch
  • Idiopathic leukoplakia
  • White sponge nevus
  • Hyperplastic candidiasis 

White sponge nevus, candidiasis, or thrush typically occurs as a flat lesion, removable by scraping, which reveals an erythematous base. However, hyperplastic candidiasis lesions are adherent and do not wipe off, making this disease especially difficult to distinguish from oral hairy leukoplakia (OHL). Resolution of the lesion with antifungal therapy suggests candidiasis over hairy leukoplakia. However, hairy leukoplakia lesions are commonly also infected with Candida, further confusing the clinical diagnosis. See the images below.

White sponge nevus. White sponge nevus.
Hyperplastic candidiasis. Hyperplastic candidiasis.

Frictional keratosis typically occurs on the lateral borders of the tongue as a consequence of tongue biting by the molar teeth or some other abrasive irritant (eg, from rubbing upon poorly fitting dental work), as shown in the image below. This lesion should quickly resolve after removal of the provoking stimulus.

Morsicatio linguarum, or tongue biting. Morsicatio linguarum, or tongue biting.

Tobacco-induced leukoplakia occurs in smokers and individuals who chew tobacco. These lesions are typically not shaggy like hairy leukoplakia, and they may occur anywhere in the oral cavity. They are often premalignant and should be evaluated by biopsy and histologic examination. See the image below.

Ventral tongue in oral leukoplakia. Ventral tongue in oral leukoplakia.

Lichen planus or lichenoid eruptions occur as autoimmune or allergic reactions to an unknown stimulus. In HIV-infected patients, lichen planus often occurs on the buccal mucosa, typically with a reticulated pattern. Oral lichen planus may also be associated with cutaneous lesions. See the image below.

Lateral tongue in lichen planus. Lateral tongue in lichen planus.

Lesions that clinically and histologically mimicked oral hairy leukoplakia but were not associated with EBV infection have been characterized as pseudo–hairy leukoplakia.

Proliferative verrucous leukoplakia can have a papillary and roughened surface, which may simulate the corrugated surface of oral hairy leukoplakia. Proliferative verrucous leukoplakia is known for malignant transformation. The two examples on the tongue and gingiva in the images below showed squamous cell carcinoma with biopsy.

 Proliferative verrucous leukoplakia of the latera Proliferative verrucous leukoplakia of the lateral tongue; biopsy showed squamous cell carcinoma.
Proliferative verrucous leukoplakia of the gingiva Proliferative verrucous leukoplakia of the gingiva; biopsy showed squamous cell carcinoma.

Differential Diagnoses