Oral Hairy Leukoplakia (OHL) is an oral mucosal lesion strongly associated with Epstein-Barr virus (EBV) infection in the context of immunosuppression.
Most commonly seen in HIV/AIDS patients but can occur in other immunocompromised states (transplant recipients, chemotherapy, long-term immunosuppressants).
Not considered pre-malignant but serves as a clinical marker of underlying immunodeficiency.

Aetiology & Pathophysiology 🧬

Reactivation of latent EBV in epithelial cells under immunosuppression → epithelial hyperplasia.
EBV replicates in tongue keratinocytes, producing characteristic “shaggy” lesions.
Strongly predictive of HIV-related immunosuppression (CD4 counts usually < 200).
Unlike leukoplakia from tobacco/alcohol, OHL does not carry malignant potential.

Clinical Presentation 🩺

White, corrugated, ‘hairy’ or shaggy plaques on the lateral borders of the tongue (pathognomonic).
Occasionally on buccal mucosa, floor of mouth, or oropharynx.
Cannot be scraped off (differentiates from candidiasis).
Usually asymptomatic, but may cause mild irritation, burning, or cosmetic concern.
Can coexist with oral candidiasis, complicating diagnosis.

Differential Diagnosis ⚖️

Oral candidiasis: White plaques, but these can often be scraped off and leave an erythematous base.
Leukoplakia: Usually due to tobacco/alcohol; has premalignant potential.
Lichen planus: Reticular, lacy white lesions (Wickham’s striae).
Squamous cell carcinoma: Ulcerated, indurated lesions; biopsy needed if suspicious.

Investigations 🔎

Clinical diagnosis often sufficient when in the right setting (HIV+ patient with classic tongue lesion).
Biopsy: Shows hyperkeratosis, parakeratosis, and “balloon cells” in upper epithelium. In situ hybridisation for EBV confirms diagnosis.
HIV testing indicated in undiagnosed patients with OHL.
PCR for EBV DNA can confirm viral involvement if diagnosis uncertain.

Management 💊

Underlying immunosuppression is key: In HIV patients, initiation or optimisation of antiretroviral therapy (HAART) often leads to regression.
Antivirals: Acyclovir/valaciclovir/ganciclovir may temporarily reduce lesions but recurrence common once stopped.
Topical therapies: Podophyllin or retinoids sometimes used but not routine.
Supportive care: Good oral hygiene, regular dental check-ups, and treatment of coexistent oral candidiasis.

Clinical Pearls ✨

💡 Cannot be scraped off – unlike oral candidiasis.
⚡ Marker lesion of HIV/AIDS: Considered an AIDS-defining illness when associated with low CD4 count.
🔬 Not premalignant: Does not progress to cancer (contrast with true leukoplakia).
🧪 OHL + oral candidiasis together in an undiagnosed patient → strong indication to test for HIV.

The content on this website is provided for educational and informational purposes only to support exam preparation (e.g., MLA, MRCP, USMLE) and learning. This is NOT medical advice, diagnosis, treatment, or professional guidance. It does not replace consultation with a qualified healthcare professional, official guidelines (e.g., NICE, GMC, BNF), or supervised clinical practice. Always verify information with current, authoritative sources. Makindo and its contributors accept no liability for any reliance on this content, including errors, omissions, or any resulting harm, loss, or consequences. By using this site, you agree to these terms.

Hairy Leukoplakia

ℹ️ About