Oral lesions

Oral Manifestations of Dermatological Disorders

By
Dr. Hala AL- Salman

Dermatological diseases, besides involving the skin and its appendages may also involve the oral cavity.
An oral mucosal lesion (OML) is defined as any abnormal change or any swelling on the oral mucosal surface. It may be a result of local pathology or secondary to other systemic disease, including those of skin and may be primary clinical feature or the only sign of these disorders.
Moreover, oral mucosal lesions in skin diseases can be life threatening and also affect the quality of life in terms of pain, discomfort, social and functional limitations.
The prevalence of OML in patients with skin diseases is about 35%.
Various groups of dermatological diseases associated with OML are as follows:
Infections.
Viral
fungal
bacterial
parasitic
2. Vesicobullous disorders
3. Lichen planus and other lichenoid disorders
4. Collagen vascular diseases
5. Vasculitic
6. Genodermatosis
7. Miscellaneous
Pemphigus vulgaris, lichen planus, candidiasis and recurrent aphthous ulcers were the most frequently diagnosed conditions.


Infections:
Viral:
Herpes simplex
Herpes simplex is caused by the herpes simplex virus (HSV). Herpetic gingivostomatitis is the most common clinical manifestation. Most cases occur in children and begin with fever, malaise and excessive dribbling. The gums are swollen and bleed easily. Vesicles presenting as white plaques and ulcers with a yellowish pseudomembrane are seen throughout oral mucosa.
Recurrences occur in 30–50% of cases of oral herpes and do not affect the buccal mucosa.

Varicella zoster virus

The varicella zoster virus (VZV) is the cause of both varicella and zoster.
Varicella (chicken pox)
After an incubation period of 2 weeks, fever and malaise, is followed by the development of papules in crops which very rapidly become clear, unilocular vesicles. In 2–4 days a dry crust forms, soon separates and heals without scarring . Similar vesicles are common in the mouth.

Zoster

The first manifestation of zoster is usually pain, followed by onset of eruption comprising of closely grouped vesicle on erythematous base in a dermatome. Mucous membranes within the affected dermatomes are also involved.
Zoster may affect the maxillary and the mandibular division of the trigeminal nerve.
In orofacial zoster, toothache may be the presenting symptom.

Herpangina.

Hand, foot and mouth disease.
HIV Infection
Dermatological manifestations of HIV infection are diverse consisting of infections, inflammatory disorders and malignancies.
Oral symptoms and signs are also common in established HIV infection.


Fungal infection:
Oral candidosis
Candidosis is an infection caused by the yeasts of the genus Candida. Superficial infections of the mucous membranes and skin are the most important.

Bacterial infection:

Syphilis
Is a chronic sexually transmitted infectious disease caused by Treponema pallidum. In primary syphilis besides the characteristic genital chancre and inguinal lymphadenopathy, extragenital indurated ulcers may be found on the lips, tongue and tosils as a result of kissing.
The secondary stage of the disease is characterized by recurrent activity of the disease, with mucocutaneous as well as systemic manifestations.

Leprosy

Leprosy is a chronic infectious disease with prominent involvement of the skin and nerves and may involve the oral mucosa that is caused by the bacillus Mycobacterium leprae.

Parasitic infection:

Leishmaniasis

Vesico-bullous disorders:

Pemphigus vulgaris
The term pemphigus describes a group of chronic autoimmune skin diseases characterised by the loss of cell–cell adhesion and widespread mucocutaneous blistering. Essentially all patients with pemphigus vulgaris develop painful erosions of the oral mucosa. 50 to 70% of patients present with oral lesions and precede cutaneous lesions by months or may be the only manifestation of the disease. These painful erosions most commonly seen on buccal and palatine mucosa are of different sizes with an irregular ill-defined border and extend peripherally with shedding of the epithelium. The lesions may extend out onto the vermilion lip and lead to thick, fissured hemorrhagic crusts.

Other bullous diseases:

Paraneoplastic pemphigus
Mucous membrane pemphigoid
Epidermolysis bullosa


Connective tissue disorders
Systemic lupus erythemotosus.
Systemic sclerosis
Sjögren’s syndrome

Lichenoid dermatosis

Lichen planus
Lichen planus (LP) is an idiopathic inflammatory disease of the skin and mucous membranes characterized by pruritic, violaceous papules that favor the extremities.
Mucous membrane lesions are very common, occurring in 30 -70%.
Lesions confined to the mouth or with minimal accompanying skin involvement, are not uncommon, accounting for about 15% of all cases and, may lead to great difficulty in diagnosis. They are often referred first to a dental surgeon.
The buccal mucosa and tongue are most often involved.

Vasculitis

Kawasaki disease
This disease also called mucocutaneous lymph node syndrome, predominantly affects young children. The onset is acute, with a high fever followed by a widespread exanthem on the limbs and trunk, swollen erythematous hands and feet and subsequent desquamation. All the mucosa and conjunctiva are injected. In the mouth, the lips are dry and fissured; the tongue appears red with prominent papillae (strawberry tongue).

Behçet’s disease

Behçet’s disease, is a multisystem disease that is defined by the presence of oral aphthosis with at least two of the following: recurrent genital aphthae, cutaneous lesions, eye lesions (uveitis) and a positive pathergy test.

Wegener’s granulomatosis

WG is classically described as a triad consisting of systemic small vessel vasculitis, necrotizing granulomatous inflammation of both the upper and lower respiratory tracts, and glomerulonephritis. The most common cutaneous manifestation of WG is palpable purpura on dependent skin sites. Oral ulcers are the second most common mucocutaneous sign of WG.


Miscellaneous
Erythema multiforme.
Stevens–johnson syndrome
Toxic epidermal necrolysis
Angio-oedema

Erythema multiforme

presenting with characteristic targetoid lesions are related to infections (especially herpesvirus) and perhaps on occasion to drug reactions
In erythema multiforme, lesions may involve the oral and genital mucous membranes in the minor form but more extensive mucous membrane involvement in the form of vesicles and erosions is seen in the major.

Angio-oedema

This is a variant of urticaria characterized by swellings of the subcutaneous tissue. Almost any part of the body may be involved, but the commonest sites are the lips, eyelids and genitalia. The lesions last for a few hours, or occasionally persist for 2–3 day. The angio-oedema especially mucosal lesions require quick management on the lines of anaphylaxis.