Topics covered in this Tutorial
Apthous Ulcers
White lesions in the mouth
Types of Oral Candidiasis
Gingivitis
Skin lesions of Behcet's
Annular Erythemas
Larva migrans
Leprosy reactions
Flushing reactions
Skin lesions of Rheumatoid arthritis
This tutorial mainly covers oral lesions.
Aphthous ulcers do not affect the gingiva, herpes simplex and Vincent’s angina do. The interpapillary area of the gums is affected by Vincent’s angina but not herpes.
What is the differential diagnosis of aphthous ulcers?
Answer
Herpes simplex both primary and secondary, Sutton’s ulcers but they scar unlike aphthous ulcers, which do not, hand foot and mouth disease, which tends to give linear vesicles, herpangina which involves the soft palate and acute pharyngitis.
Answer
Congenital causes include dyskeratosis congenita, pachyonychia congenita, white sponge nevus, familial intraepithelial dyskeratosis and Darier’s disease.
Squamous disorders are psoriasis, lichen planus and lupus erythematosus or candidiasis, syphilis and oral hairy leukoplakia. Image of severe candida Image of oral syphilis
Neoplastic conditions are squamous cell skin cancer and traumatic conditions are cheek biting. Submucosal fibrosis is also due to trauma. It is seen in Indians on the hard palate and they also show some mottled pigmentation. Image of Leukoplakia SCC floor of mouth
The image below is oral hairy leukoplakia
What types of oral candidiasis do you know?
Answer
Acute atrophic, acute pseudomembranous, which is the ordinary type we see, chronic atrophic sometimes known as the edentulous sore mouth, median rhomboid glossitis, chronic hypertrophic and chronic mucocutaneous candidiasis. The types of the latter include familial, endocrine with hypoparathyroidism, thymoma and the immunosuppressed and acquired immunodeficiency types.
Note that a white sponge nevus is in the floor of the mouth or the buccal mucosa. It does not involve the tongue. Also if you have a white lesion in the mouth always look at the anus and perianal skin. In dyskeratosis congenita and pachyonychia congenita the oral lesions occur in the second decade. Lupus erythematosus of the mouth involves the buccal mucosa with a leukoplakia like lichen planus. Patients who have secondary syphilis white lesions in the mouth often have an associated pharyngitis. Note that the gingiva and the hard palate are keratinising surfaces. Aphthous ulcers never go on the gingiva and this can be compared with herpetic ulcers which do.
The image below is oral candidiasis
Consider herpes simplex, Vincent’s angina, leukaemia, vitamin C deficiency, bacterial infection, cyclic neutropenia and histiocytosis X, lichen planus and mucocutaneous pemphigus.
Question
What are the causes of marked cheilitis of the lips?
Answer
Stevens-Johnson syndrome, lupus erythematosus, pemphigus, herpes simplex and toxic epidermal necrolysis. These will involve both lips generally although lupus and lichen planus can just involve the lower lip and of course actinic cheilitis mainly involves the lower lip. Rarely contact dermatitis.
The image below is granulomatous cheilitis
 |
| Discoid lupus erythematosus lips |
What are the skin lesions of Behcet’s disease?
Answer
Aphthous ulcers, genital ulcers, pustules at the sites of trauma, pyoderma gangrenosum, thrombophlebitis erythema nodosum and vasculitis. There may also be compliment deficiencies. Image scrotal ulcers Behcet's
Last thoughts. Note that mucous membrane pemphigoid or cicatricial pemphigoid does not necessarily give scarring in the mouth and that junctional epidermolysis bullosa may give mottled teeth and severe bullae in the mouth.
The image below is multiple apthous ulcers in Behcets syndrome
Some Annular Erythemas
Consider the following:
1. In erythema marginatum the illness may last several weeks but individual lesions are short lived. They may be raised, rarely purpuric and they are urticarial in the centre.
2. With Still’s disease there is a diffuse macular eruption with sometimes central pallor. Differential diagnosis is often rubella, adeno viruses and infectious mononucleosis but they tend to have just an evanescent rash.
3. Erythema infectiosum may clear up and then recur again. It can go on for up to six weeks. Note the rash on the buttocks and the outer aspects of the arms is often reticulate or net like. It particularly involves the buttocks, thighs and arms and this reticulate erythema occurs after the slapped cheek presentation.
The image below is Erythema marginatum
 |
| Erythema marginatum |
 |
| Erythema infectiosum |
Larvae migrans has an advancing edge but it may curl back on itself. Larvae currens moves faster and it is due to Strongyloides stercoralis whereas larvae migrans is the hook worm Ancylostoma Braziliensis. Image of larva migrans
The image below is Larva migrans
When there is some downgrading, i.e. there is less of an immune reaction, you get more lesions and there are more bacilli in the lesions. When there is upgrading you will get a swelling of existing lesions and nerves, i.e. you are developing a more intense immune reaction. Erythema nodosum leprosum is actually an allergic reaction and is a common cause of vasculitis. Image in GSA
What are the clinical features of leprosy lesions?
Tuberculoid leprosy has hypopigmented lesions with a lack of sweating, lack of hair, thickened nerves and papules just inside the advancing edge. Borderline tuberculoid leprosy has a sharp inside edge and diffuse outer edge. Sensation is down and sweating is down as well. Image Indeterminate is macular with hypopigmentation in darker skin. The adnexae are usually okay. There are a few bacilli. Indeterminate leprosy is pink in light skin. Image Borderline lepromatous leprosy has a raised ring surrounding a central flat immune area. Lepromatous leprosy has macules, nodules, infiltrates mainly in the ears and the nose with some congestion. There is a negative lepromin test.
Lucio’s phenomenon gives diffuse erythema, often with a lack of the eyebrow edge and it is seen in Mexico. In tuberculoid leprosy the histology shows tuberculoid granulomas around the adnexae with associated Langerhans giant cells.
The image below is a leprosy reaction
These include the carcinoid syndrome, phaeochromocytoma, Zollinger Ellison, mastocytosis, hyperthyroidism, perimenopausal and flushing associated with angiokeratoma corporis diffusum.
Skin Lesions in Rheumatoid Arthritis
Remember leg ulcers due to vasculitis or pyoderma gangrenosum. You can get sclerodermoid changes, bullae, nodules and other types of vasculitis. On the fingers you will get gangrene and infarcts
The image below is flushing in Carcinoid syndrome
Other bon mots
Hydro vacciniforme occurs in boys and causes scarring of the face. Image
The Lawrence Seip syndrome gives acromegalic looking children with lipodystrophy and from memory I think they also have acanthosis nigricans.
If you have an advancing edge on a lesion then always think of fungi, tumour, granuloma annulare, leprosy, other granulomas and erysipelas.
Common causes of hard firm fingers are diabetic stiff skin syndrome, scleroderma, scleromyxedema and amyloidosis.
Periocular papules may be due to acnitis or granulomatous rosacea, syringomas, Cowden’s disease or lipoid proteinosis.
Leprosy can involve the tip of the tongue but a tuberculous ulcer is almost always on the back of the tongue.
What are the types of lipodystrophy?
There is the localised which can be ringed or due to trauma. The ringed type can be inflammatory and nevoid. Inflammatory is especially likely with the collagen diseases. There is also the Parry Romberg syndrome on the face with hemiatrophy. Partial lipodystrophy involves the upper half of the body. Image The legs are usually okay and in total lipodystrophy all the parts of the body can be involved and an example is the Lawrence Seip syndrome.
The image below is acnitis of the scalp margin.
