How can psoriasis affect the mouth and tongue?
Psoriasis can affect any area of skin, including that of the mouth and tongue. The condition can cause cracks to form on the tongue or smooth patches, in a complication called geographic tongue.
Psoriasis is a chronic autoimmune condition. It causes a person’s skin to grow faster than average, resulting in red and often scaly patches of skin.
These patches can form anywhere on the body. According to the National Psoriasis Foundation, the most common areas are the scalp, elbows, and knees.
Less frequently, psoriasis affects the mouth. Oral psoriasis can cause red patches with yellow or white edges to form on the tongue.
Read on to learn more about the symptoms, risk factors, and treatments for psoriasis on the tongue.
Symptoms of psoriasis on the tongue
Psoriasis can cause noticeable changes in the color, texture, and feeling of the tongue.
For example, people with psoriasis are more likely to develop an inflammatory condition called geographic tongue, or erythema migrans.
The condition stems from an issue with the immune system. It causes the tongue’s skin cells to grow and shed at an irregular rate, resulting in smooth patches.
An estimated 10 percent of people with psoriasis experience geographic tongue, compared to 1–2 percent of the general population.
Symptoms of psoriasis on the tongue include:
- red patches with yellow or white borders
- swelling and redness on the tongue
- smooth patches
- fissures or cracks in the surface of the tongue
Psoriasis on the tongue can be tricky to diagnose because signs may be mild or even unnoticeable.
However, for some people, these symptoms can lead to pain or swelling so severe that it makes eating or drinking difficult.
Authors of a concluded that identifying the cause of issues such as geographic tongue can be difficult. Not all people with geographic tongue have psoriasis, but the two conditions are likely linked.
A thorough examination and testing can help a doctor determine if a person with geographic tongue has oral psoriasis.
How does psoriasis affect the mouth, gums, and lips?
Psoriasis typically does not affect the mouth. When it does, people may experience the following symptoms:
- peeling skin on the gums
- sores or pustules in or around the mouth
- pain or a burning sensation when eating hot or spicy foods
- a noticeable change in taste
In most cases, the patches or sores will appear on the inside of the cheeks.
Risk factors for psoriasis on the tongue
According to the National Psoriasis Foundation in the United States, about 10 percent of people are born with one or more gene that makes them prone to psoriasis in general. However, only 2–3 percent of these people actually develop the condition.
To develop psoriasis, a person must have at least one of the relevant genes and be exposed to triggers.
Several factors can trigger psoriasis, including:
- injury to the skin
Psoriasis may affect only one area of the body or several, and it may arise in new places. No matter where it occurs, psoriasis is not contagious, so a person cannot pass on the condition to others.
Many treatments can help people manage their psoriasis symptoms.
Oral psoriasis sometimes requires no treatment. However, consult a doctor if the symptoms interfere with daily activities.
The doctor may prescribe anti-inflammatories or topical anesthetics for people with oral psoriasis. These medications can help reduce inflammation and pain, making it easier to eat and drink.
A person may notice improvements in oral psoriasis if they treat body-wide symptoms. Typically, when treating psoriasis, a doctor will prescribe medications, such as:
To prevent psoriasis symptoms from flaring up, it can help to avoid triggers. For psoriasis on the tongue, a person can:
- avoid spicy or very hot foods
- quit smoking
- use mouth rinses
- practice good oral hygiene
It can also help to reduce stress, which can worsen symptoms.
Psoriasis is a chronic condition that forms patches of dry or broken skin. It can affect skin on any part of the body, including the tongue and mouth.
A person can manage symptoms by avoiding triggers and taking medication. Triggers can include certain foods, some medicines, and stress.
Seek treatment for psoriasis, even if symptoms are mild. A doctor can develop an overall treatment plan to help reduce the number of flare-ups.
Some people with psoriasis find that it affects their mental health. Counselors can provide support.
Oral Psoriasis of the Tongue: A Case Report
Monitoring Editor: Alexander Muacevic and John R Adler
William J Ferris
1 Orthopaedics, Georgetown University Hospital, Washington, D.C, USA
Find articles by William J Ferris
2 Otolaryngology, Georgetown University Hospital, Washington, D.C, USA
Find articles by Suzette Mikula
3 Dentistry, Howard University, Washington, D.C, USA
Find articles by Ronald Brown
4 Pathology, Howard University, Washington, D.C, USA
Find articles by Andre Farquharson
Author informationArticle notesCopyright and License informationDisclaimer
1 Orthopaedics, Georgetown University Hospital, Washington, D.C, USA
2 Otolaryngology, Georgetown University Hospital, Washington, D.C, USA
3 Dentistry, Howard University, Washington, D.C, USA
4 Pathology, Howard University, Washington, D.C, USA
William J. Ferris [email protected]
Received 2019 Nov 4; Accepted 2019 Dec 5.
Copyright © 2019, Ferris et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Psoriasis is a common dermatological disease, but oral psoriasis is rarely reported in the literature. Its diagnosis has been a contentious issue among physicians. Its presence in the absence of skin lesions is not completely accepted by all physicians, and diagnosis is complicated by the fact that there are no defined criteria. We present a case report of oral psoriasis in a man who did not have skin lesions concurrently but did have a previous history of dermal psoriasis. Additionally, we discuss the history, typical presentation, and current treatments of oral psoriasis.
Keywords: psoriasis, tongue
Psoriasis is a relatively common immune-mediated, chronic, genetically determined, scaly inflammatory disease that primarily affects the skin and secondarily the joints. Various sources have noted that the prevalence rate of this condition ranges between 0.5-4.6% of the population worldwide. The most common form of psoriasis is the plaque type, also known as psoriasis vulgaris, which accounts for approximately 90% of occurrences. The most common anatomical presentations of these lesions occur on the elbows, knees, scalp, fingernails, and toenails [1-5].
Oral psoriasis of the tongue is an extremely rare condition. Oppenheim first reported on the histopathology of oral psoriasis in 1903 . In 1997, Younai and Phelan reported that only 57 cases met the criteria to be confirmed as cases of oral psoriasis. Lier et al. (2009) reported that the occurrence of true psoriatic oral mucosal lesions had been disputed in the past and only seven more cases had been identified as of 2009. Of these 64 reported cases, only 11 have demonstrated characteristic psoriatic lesions of the tongue, and in five of these 11 cases, cutaneous psoriatic lesions were not present . Mattsson et al. (2015) noted that the diagnosis of the oral mucosal psoriatic lesion is problematic as there are no clinical or histopathologic criteria. Another factor that further complicates the diagnosis is the variable appearance of lesions diagnosed as oral mucosal psoriatic lesions .
Van der Wall and Pindborg (1986) described four types of clinical presentations of oral psoriasis: 1) well-defined, gray to yellowish-white, very small roundish lesions; 2) lacy, circinate, elevated white lesions of the oral mucosa, including the tongue, which paralleled cutaneous lesions; 3) fiery-red erythematous oral lesions corresponding with acute cutaneous lesions; and 4) benign migratory glossitis (BMG), which occurs more frequently in patients with cutaneous psoriasis .
The association of psoriasis with both fissured tongue and BMG (also known as geographic tongue) is well documented. The prevalence of fissured tongue ranges between 9.8-47%, and the prevalence of BMG ranges between 5.6-8.1% in patients with cutaneous psoriasis [2,9]. The prevalence of BMG overall is between 1-2% of the population . Picciani et al. reported that the oral condition called fissured tongue has an incidence of between 5-10% among the global population .
A 66-year-old patient presented to a private oral medicine clinician in early November 2017 with a chief complaint of “burning tongue, red at the tip, white bumps in the rear, cuts in tongue lesion, and bad taste.” His physician had previously placed him on a nystatin topical rinse for one week without any resolution of the condition. The condition had been ongoing for approximately two and a half months and the patient also reported difficulty in speaking. The patient had replaced his usual toothpaste with a toothpaste that was supposedly free of sodium lauryl sulfate. Eating spicy foods was not problematic. The patient’s pain was negligible upon waking up but increased as the day progressed. The condition did not interfere with his sleep. The patient was taking apixaban for atrial fibrillation, atorvastatin for cholesterol, lansoprazole for gastric reflux, and fexofenadine and azelastine for seasonal allergies, along with a vitamin D supplement. The patient reported no known drug allergies. Clinically, no lymphadenopathy was noted. The anterior dorsal tongue was noted for erythema, and the remaining oral tissues appeared to be within normal limits (Figure 1).
The differential diagnosis consisted of hypersensitivity reaction, irritation reaction, oral candidiasis, and dysgeusia. The patient was referred to an allergy and immunology physician for food hypersensitivity evaluation in late November, and the evaluation studies were negative. The patient reported that his tongue seemed to be doing better and he suspected the reason was that he had removed paprika from his diet. However, the patient’s oral burning symptoms returned in January and he was scheduled for a biopsy procedure. The biopsy procedure and histological examination were performed in late January 2018. The pathology was positive for periodic acid-Schiff (PAS) staining for candidiasis. The histopathology slide at medium magnification exhibited elongated rete pegs (Figure 2). The papillary connective tissue was noted for lymphocytic inflammation and dilated blood vessels approximating the epithelial margins. Lower magnification showed marked collections of neutrophils seen in the parakeratin, which was consistent with Munro abscesses. The patient was placed on a two-week regimen of 100 mg fluconazole tablets daily. But the patient's condition further deteriorated (Figure 3). The patient was then referred to otolaryngology for a fungal DNA identification culture and sensitivity assay. The culture was negative for candida, aerobic, anaerobic, or acid-fast bacilli. The otolaryngologist elucidated that the patient had previously been treated for cutaneous psoriasis, and the patient also reported a history positive for psoriasis which had begun in his teens. The patient reported that he had had dry red blotchy lesions of the legs, trunk, and face. His dermatologist had prescribed calcipotriene ointment for the trunk and leg lesions and desonide for his facial lesions. The medications had been sufficient to control the condition. The patient did not remember having psoriatic lesions when the tongue lesions first presented in the late summer of 2017, although he was not sure whether there had been cutaneous psoriatic lesions at that time. The oral medicine clinician came up with a new working diagnosis of oral psoriasis and prescribed a regimen of topical dexamethasone elixir rinse. The patient’s lesions subsequently resolved (Figure 4). The patient was asked to discontinue the steroid rinse as a challenge and, in two weeks, the erythema and sensitivity returned (Figure 5). On resuming the topical steroid regimen, the lesions once again resolved. The patient was referred to his dermatologist to consider a biologic therapeutic, but the dermatologist deferred as he felt that the topical rinse seemed to be effective and was a more conservative approach.
As demonstrated by this case, oral psoriasis lesions are often misdiagnosed for other, more common pathologies. A definitive diagnosis can be challenging due to several factors including an unclear etiology, ill-defined clinical and histopathologic criteria, and rare occurrence with a variety of presentations. A differential diagnosis for any suspected oral psoriasis lesion should include lichen planus, syphilis, lupus erythematous, cicatricial pemphigoid, pemphigus, candidiasis, reactive arthritis, and smoking or trauma . The correct diagnosis, in this case, relied on a careful study of the patient's history, physical exam, and biopsy with histological examination.
Most oral psoriasis lesions appear in the context of cutaneous lesions, either presenting simultaneously or appearing in patients with a history of cutaneous psoriasis . A careful analysis of the patient's history is crucial to elucidating such crucial details. After the patient's history is examined, it is imperative to conduct a thorough exam of the patient’s skin for psoriatic lesions. Such lesions are often asymptomatic and may be in progression or regression unbeknownst to the patient. Identification of any cutaneous psoriatic lesions would elevate the diagnosis of oral psoriasis in the differential.
Isolated cases of oral psoriasis have been reported and the diagnosis cannot be ruled out based on a negative history and physical exam alone. A biopsy with periodic acid-Schiff-diastase (PAS-D) staining is often useful to distinguish between a superficial fungal infection and psoriasis. In general, pathologic changes seen within the mucous membranes parallel those of cutaneous psoriasis-elongation and thickening of rete ridges with overall acanthosis. The papilla of the lamina propria is elongated and edematous . More specific immunohistochemical staining for factors such as vascular endothelial growth factor (VEGF) and tumor necrosis factor (TNF) is useful in a more definitive diagnosis of oral psoriatic lesions . Even so, as reported in this case, initial biopsies may be misleading and continued follow-up and flexibility in treatment are fundamental to arriving at the correct diagnosis. In the case presented, the biopsy initially reported inflamed oral mucosa with candidiasis. However, after refractory antifungal treatment, a subsequent biopsy was performed that was negative for candidiasis, which led the clinician to inquire more about possible cutaneous psoriasis whereupon the patient revealed a history of dermal psoriasis in his teenage years. Patients with dermal psoriasis are known to be more susceptible to oral psoriasis or geographic tongue. Histologically, oral psoriasis and geographic tongue are similar in characteristics but occur in different locations. Often, geographic tongue exhibits a prominent white serpentine border and erythematous center while oral psoriasis has a white border that is either less prominent or not present at all.
Management of oral psoriasis covers a spectrum of treatments ranging from nonintervention to biomarker testing and biologic therapy to skin grafting. For asymptomatic lesions, treatment is not necessary and, undoubtedly, many of these lesions are unreported. Commonly, oral psoriasis can cause erythema, bleeding, plaque, or ulcers, and symptoms of discomfort such as pain, loss of taste, and hypersensitivity. For irritant-driven lesions, lifestyle modifications that focus on removing the irritant are preferred. Common irritants include spicy foods, smoking, and abrasive dentures or teeth. For nonirritant-related lesions, first-line treatment typically centers around palliative care using topical anesthetics such as viscous lidocaine, diphenhydramine, and alkaline rinses, which have all been reported to provide relief. Corticosteroids are also useful in reducing inflammation and suppressing the migration of polymorphonuclear lymphocytes . Often, regression of the psoriatic lesion is observed and such patients have a good prognosis in the long term. For patients refractory to this care, advances in the understanding of cytokines and inflammatory disease processes have introduced a new field in the therapeutic treatment of psoriasis. Historically, anti-TNF agents developed for rheumatology and gastroenterology have been used with some success in treating psoriasis. Etanercept, introduced in 2004, was the first Food and Drug Administration (FDA)-approved biologic for dermatologic treatment and has a safe and effective record . Recently, significant progress has been made in understanding the role of the Interleukin-23 (IL-23)/T-helper 17 (Th17) signaling pathway in immune-mediated diseases. Biologics such as ixekizumab and secukinumab that disrupt Interleukin-17 (IL-17), or its receptor in the case of brodalumab, are highly effective and safe in treating moderate to severe psoriasis . To conclude, these therapies are primarily intended to treat dermal psoriasis, but with the close relation and often co-presentation of both dermal and oral psoriasis, the clinician may consider their use in severe oral psoriasis. In the case of our patient, biologic treatment was not pursued since the topical rinses were effective.
Currently, research is being conducted in the field of biomarkers for the strategic diagnosis and treatment of psoriasis. Unfortunately, no biomarkers specific to psoriasis of any type have been identified so far. However, researchers remain hopeful that biomarkers will yield novel strategies and treatments to improve patient management and outcomes . Surgical procedures such as gingival grafting should be reserved for candidates refractive to medical therapy.
Lastly, consideration must be given to the simultaneous presentation of oral psoriasis with another disease on the differential, most often candidiasis. While the treatment of many oral lesions is straightforward, an astute clinician must always consider the potential overlap of multiple disease processes, which may complicate both the diagnosis and treatment.
While rarely reported, oral psoriasis is a diagnosable lesion with effective and adequate treatments. The patient presented follows the classic storyline of misdiagnoses and mistreatment that often happens due to a misleading biopsy and/or incomplete history. Although cases of isolated oral psoriasis have been reported, patient history or physical-exam findings pertaining to cutaneous psoriasis is a notable clue in diagnosing oral psoriasis. Treating oral psoriasis should be pursued in a gradual, step-wise fashion, beginning with irritant removal and gradually advancing to palliative care and eventually biologic therapy based on the requirement. Grafting and other surgical procedures should be considered after all the medical treatment avenues have been considered. To sum up, oral psoriasis is an uncommon ailment that can be effectively diagnosed and treated through common medical practices including a thorough study of the patient history, methodical physical exam, confirmatory testing, and continued patient-physician dialogue.
The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.
The authors have declared that no competing interests exist.
Consent was obtained by all participants in this study
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Articles from Cureus are provided here courtesy of Cureus Inc.
Author: Kim Gear, Oral Medicine Trainee, Auckland, New Zealand, 2007.
What is oral psoriasis?
Oral or intraoral psoriasis is psoriasis affecting the inside the mouth.
Psoriasis is a chronicinflammatory skin disorder affecting 1-3% of the world population. It most often starts in the second and third decades of life. It affects males and females equally.
What is the clinical presentation of oral psoriasis?
There are several ways psoriasis may present. The most frequent is psoriasis vulgaris or chronic plaque psoriasis, in which there are persistent or recurring scalyplaques (thickened patches of skin). The extent of psoriasis varies from a few localised plaques on the elbows, knees, lower back and scalp to the involvement of the skin of the whole body. A pustular form of psoriasis may also occur.
Psoriasis inside the mouth is relatively uncommon. It is more likely to develop in those with the more severe forms of psoriasis, especially pustular psoriasis. There are several types of oral lesion.
- Irregular red patches with raised yellow or white borders, similar to geographic tongue. This is the most common.
- Redness of the oral mucosa
- Peeling gums, called desquamative gingivitis
- Pustules (in pustular psoriasis)
How is the diagnosis of oral psoriasis made?
The diagnosis of oral psoriasis is usually made from the clinical appearance, in a patient who has known psoriasis. A biopsy can help to confirm the diagnosis.
Under the microscope, psoriasis is characterised by thickened epithelium with long rete ridges and chronic inflammation. Small collections of lymphocytes form microabscesses within the epithelium along with migrating polymorphonuclearleukocytes.
What is the management of psoriasis?
Psoriasis may be managed using a variety of topical and systemic treatments.
Treatment for oral psoriasis may include:
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Oral Psoriasis: How the Disease Can Affect Your Mouth
Why Diagnosing Oral Psoriasis Can Be Tricky
According to a study published in June 2016 in the journal Dermatology, diagnosing oral psoriasis is challenging because it can trigger different symptoms that resemble other conditions affecting the mouth and lips, such as stomatitis, oral thrush, or chronic eczema. Symptoms may include oral pain, burning, or changes in taste perception.
A case study published in January 2013 in the European Journal of General Dentistry described one patient’s oral psoriasis symptoms as including “gum bleeding, chronic irritation, intolerance to salt and spicy food, and frequent occurrence of painful mouth ulcers with a fissured tongue.”
Is It Oral Psoriasis or Geographic Tongue?
“People who have psoriasis may be more prone to a condition called geographic tongue,” says Dr. Chase. The American Academy of Oral Medicine describes this as an inflammatory condition that typically appears on the top and sides of the tongue.
While it doesn’t cause pain, the condition can change the tongue’s appearance with red areas of varying size surrounded by a white border. It’s believed that 10 to 15 percent of people with psoriasis will develop geographic tongue at some point in their lifetime.
How to Prevent and Treat Symptoms of the Mouth
According to Estee Williams, MD, a dermatologist in New York City, there are some things patients can do to minimize the risk for oral psoriasis.
“First and foremost, I recommend maintaining good oral hygiene, including use of any alkaline mouth rinses,” Dr. Williams says. A do-it-yourself rinse can be made from baking soda and water.
Smoking is a risk factor for a variety of oral problems. “If you smoke, stop immediately,” Williams says. Also, avoid alcohol and find ways to manage stress, both of which are common psoriasis triggers.
“Another way to ward off any oral issues is to have regular dental checkups,” Williams adds.
If you have red and white patches or lesions in your mouth, your dentist may want to perform an oral tissue biopsy. While it may not establish that you have oral psoriasis, a biopsy can help diagnose or rule out other conditions, such as cancer.
Your doctor may recommend an anesthetic rinse, such as Xylocaine Viscous (lidocaine), a hydrochloride solution, if you have an oral irritation that is causing pain. For more severe cases, you may be prescribed anti-inflammatory drugs, such as corticosteroids. But systemic treatment usually isn’t usually recommended if the symptoms are limited to your mouth.
Tongue psoriasis photos on
What You Should Know About Psoriasis on the Tongue
What is psoriasis?
Psoriasis is a chronic autoimmune condition that causes inflammation and rapidly growing skin cells. As the skin cells accumulate, it leads to patches of red, scaly skin. These patches can appear anywhere on your body, including in your mouth.
It’s rare, but psoriasis can also occur on the tongue. Psoriasis on the tongue may be linked with an inflammatory condition affecting the sides and top of the tongue. This condition is called geographic tongue.
Geographic tongue is more likely to occur in people who have psoriasis. More research is needed to understand this connection.
Signs and symptoms of psoriasis on the tongue
Psoriasis can cause periodic flare-ups of symptoms, after which there’s little or no disease activity.
Since you can have psoriasis anywhere on your body, it’s also possible to have it in your mouth. This includes the:
Lesions on the tongue can vary in color, from white to yellowish-white to gray. You might not notice lesions at all, but your tongue may be red and inflamed. This usually occurs during an acute psoriasis flare-up.
For some people, there are no other symptoms, which makes it easily overlooked. For others, pain and inflammation can make it hard to chew and swallow.
Who is at risk for psoriasis on the tongue?
The cause of psoriasis isn’t known, but there’s a genetic link. That doesn’t mean you’ll get it if others in your family have it, but it does mean you have a slightly higher risk for developing psoriasis than most people.
Psoriasis also involves an over reactive immune system response. In some people, flare-ups seem to be caused by specific triggers, such as emotional stress, illness, or injury.
It’s a fairly common condition. According to the National Psoriasis Foundation, more than 8 million people in the United States are living with psoriasis. It can develop at any age. It’s most likely to be diagnosed when you’re between the ages of 15 and 30.
Psoriasis can show up in any part of your body. Doctors aren’t sure why it flares up in the mouth or tongue in some people, but it’s a very uncommon location.
Psoriasis and geographical tongue aren’t contagious.
Should I see a doctor?
See your doctor or dentist if you have unexplained bumps on your tongue or have trouble eating or swallowing.
Be sure to tell your doctor whether you’ve previously been diagnosed with psoriasis, especially if you’re currently having a flare-up. Your doctor will probably consider this information first.
Psoriasis on the tongue is rare and easy to confuse with other oral conditions. These include eczema, oral cancer, and leukoplakia, which is a mucous membrane disease.
You may need tests, like a biopsy of your tongue, to rule out other possibilities and to confirm you have psoriasis.
What are the treatment options for psoriasis on the tongue?
If you don’t have pain or trouble chewing or swallowing, treatment may not be necessary. Your doctor may suggest a wait-and-see approach.
You may be able to help keep your mouth healthy and relieve mild symptoms by practicing good oral hygiene. Prescription-strength anti-inflammatories or topical anesthetics can be used to treat pain and swelling.
Psoriasis of the tongue can improve when you treat your psoriasis in general. Systemic medications are those that work all throughout your body. They include:
These drugs are particularly useful when topical medications don’t help.
Learn more about what injections you can use to treat psoriasis.
What’s the outlook for people with psoriasis?
There’s no cure for psoriasis. However, treatment can help you effectively manage the disease and ease its symptoms. There’s no way to know if you’ll have more flare-ups that involve your tongue, though.
If you’ve been diagnosed with psoriasis, you’re at greater risk for some other conditions, including:
Psoriasis is a lifelong condition. It’s important to find a dermatologist to help you monitor and manage it.
The visibility of psoriasis may make you feel self-conscious, leading to feelings of depression or isolation. If psoriasis is interfering with your quality of life, tell your doctor.
You may also want to find in-person or online support groups specifically geared toward living with psoriasis.
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