Erythroplakia

§ overviewOverview

WHO: 'A fiery red patch that cannot be characterised clinically or pathologically as any other definable disease.' Considered an oral potentially malignant disorder (OPMD).

§ icdICD Classification

ICD-10 K13.29

§ etiologyEtiology

• 01Heavy tobacco use
• 02Alcohol (synergistic)
• 03Areca nut
• 04Chronic Candida infection
• 05HPV (subset)

§ riskRisk Factors

• 01Male, 60–70 years
• 02Combined tobacco + alcohol
• 03Poor oral hygiene

§ geneticsGenetics & Molecular Biology

• 01Frequent TP53 mutations, LOH at 3p and 9p
• 02High DNA aneuploidy — strong progression marker

§ epidemiologyEpidemiology

Rare — prevalence 0.02–0.1%. Middle-aged to elderly men. Southeast Asia higher due to habits.

§ pathogenesisPathogenesis

Atrophic, non-keratinised epithelium overlying dysplastic or malignant cells → underlying vasculature shows through, producing bright red colour. Represents advanced field change on the OPMD spectrum.

§ clinicalClinical Features

• 01Bright red, velvety, well-demarcated plaque
• 02Flat or slightly depressed, soft on palpation
• 03Common sites: floor of mouth, ventral/lateral tongue, soft palate, retromolar area
• 04May be mixed with white areas (erythroleukoplakia)
• 05Usually asymptomatic; mild soreness or metallic taste

§ signsSigns & Symptoms

• 01Painless red patch
• 02Occasional burning or roughness
• 03Bleeds on gentle probing

§ differentialDifferential Diagnosis

• 01Erythematous candidiasis
• 02Lichen planus (atrophic/erosive)
• 03Mucositis
• 04Contact stomatitis
• 05Kaposi sarcoma
• 06Discoid lupus
• 07Early SCC

§ criteriaDiagnostic Criteria

• 01Diagnosis of exclusion; incisional biopsy mandatory in every case

§ histopathHistopathology

• 01Severe epithelial dysplasia, carcinoma in situ or invasive SCC in > 90% of cases at first biopsy
• 02Atrophic epithelium with reduced or absent keratinisation
• 03Sub-epithelial chronic inflammation and vascular ectasia (produces red colour)
• 04Loss of basement membrane integrity indicates invasion

§ investigationsInvestigations

• 01Toluidine blue (strongly positive)
• 02Autofluorescence loss
• 03Incisional/excisional biopsy — GOLD STANDARD
• 04HPV testing if history suggestive

§ ihcIHC / Special Stains

• 01p53 diffuse positivity
• 02Ki-67 full-thickness proliferation
• 03Cyclin D1 over-expression

§ whoWHO Classification

Classified under Oral Potentially Malignant Disorders (WHO 2022). Highest per-lesion transformation risk of all OPMDs.

§ classificationClassification

• 01Homogeneous erythroplakia
• 02Erythroleukoplakia (mixed red + white)
• 03Granular / speckled erythroplakia

§ planTreatment Planning

• 01Immediate biopsy of every red patch persisting > 2 weeks after removing irritants
• 02Complete surgical excision regardless of grade due to high malignant potential
• 03Neck assessment if invasive SCC found

§ treatmentTreatment

• 01Habit cessation
• 02Complete surgical excision with 5 mm margin
• 03CO2 laser excision acceptable for superficial lesions
• 04Definitive oncologic management if invasive SCC

§ medicalMedical Management

• 01Adjunctive antifungals if Candida co-infection
• 02Chemopreventive retinoids — limited evidence

§ surgicalSurgical Management

• 01Wide local excision with clear margins
• 02CO2 laser or cold-knife based on size and site
• 03Reconstruction with primary closure, secondary intention or graft

§ complicationsComplications

• 01Progression to invasive SCC
• 02Recurrence at margins
• 03Post-excisional scarring, tethering

§ recurrenceRecurrence Rate

Recurrence 20–30% even after complete excision; new lesions common due to field cancerisation.

§ followupFollow-up Protocol

• 01Monthly for first 3 months, then 3-monthly for 2 years, 6-monthly lifelong
• 02Re-biopsy any recurrence or new red area

§ prognosisPrognosis

Highest malignant potential of all OPMDs — up to 50% harbour or progress to invasive SCC within 5 years.

§ preventionPrevention

• 01Tobacco / alcohol / areca cessation
• 02Oral cancer screening in high-risk populations

§ examKey Examination Points

• 01Site, size, colour uniformity
• 02Induration and fixity
• 03Cervical lymph nodes
• 04Habit history

§ revisionQuick Revision Summary

• 01Red > white in risk
• 02> 90% dysplasia / CIS / SCC at first biopsy
• 03Excision mandatory regardless of grade
• 04Lifelong follow-up

§ vivaBDS Viva Questions

• 01Define erythroplakia.
• 02Why is it more dangerous than leukoplakia?
• 03What is the commonest histological finding?
• 04How is it managed?
• 05Name three differentials for a red mucosal patch.
• 06What is erythroleukoplakia?
• 07What is toluidine blue staining and its use here?
• 08What is field cancerisation?

§ bdsBDS Professional Examination

• 01Compare and contrast leukoplakia and erythroplakia (10 marks).
• 02Short note: Erythroplakia.

§ fcpsFCPS Residency Questions

• 01Discuss oral potentially malignant disorders with special reference to erythroplakia — molecular basis, clinical evaluation, and evidence-based management.

§ pearlsClinical Pearls

• 01Red > white — erythroplakia is more ominous than leukoplakia.
• 02Any red patch not diagnosable as candidiasis or lichen planus must be biopsied.
• 03Toluidine blue helps localise most dysplastic zones.

§ mnemonicsMnemonics

• 01RED = Really Every Dysplastic — biopsy every red patch

§ readingSuggested Reading

• 01Reichart PA, Philipsen HP. Oral erythroplakia — a review. Oral Oncol 2005.
• 02WHO Head & Neck Tumours 5e (2022).

§ differentialDifferential Comparison

§ mcqsMCQs — Assessment (5)

§ relatedRelated Diseases

References

1. Neville BW et al. Oral & Maxillofacial Pathology, 4e
2. Warnakulasuriya S. Oral Oncol 2020
3. WHO Classification of Head and Neck Tumours, 5e (2022)