Aphthouslike ulcerations

Aphthous ulcerations are ulcerations of the oral cavity that typically cannot be classified as due to any other infectious agent. In immunocompetent individuals, these ulcerations (termed canker sores in the vernacular) usually affect only the nonkeratinized surfaces of the oral cavity. However, in immunocompromised hosts, these ulcerations can appear anywhere. Although 3 forms of recurrent aphthous ulcerations are recognized (ie, minor, major, herpetiform), the major form is more common in persons with HIV disease. The appearance of these lesions in an HIV-infected patient is a reliable indicator of severe immunodeficiency and disease progression.

Aphthous lesions manifest as yellowish-gray areas of ulceration ranging in size from a few millimeters to larger than a centimeter. The ulcerations are surrounded with a halo of erythema and are usually very painful. Major aphthae are larger than 1 cm in diameter and heal in 14-21 days. Major aphthae differ from the other forms of the condition in that they can heal with scarring.

Aphthouslike ulcerations can be treated with a wide array of immune-modulating agents that can be delivered via topical, intralesional, or systemic means. Practitioners should be careful with topical immunosuppressants in this patient population because of the risk of candidal overgrowth that can accompany these agents. Patients who cannot tolerate the adverse effects or additional immunocompromise from the immunosuppressive agents can sometimes be treated with thalidomide.

Because so many conditions in HIV-affected individuals can manifest with ulceration of the oral cavity and because the presentations are often atypical, biopsy is indicated for definitive diagnosis of all HIV-related ulcerations.

CUTANEOUS DISEASES

Psoriasis

Psoriasis is a chronic papulosquamous inflammatory condition of the skin. It affects 2% of the US population. Psoriasis generally occurs in the second or third decade of life and shows no sexual bias. The extent and severity of the disease vary greatly between individuals. Its etiology is unknown. The scalp, elbows, or knees are typically affected with characteristic scaly, white, well-demarcated plaques. When the silvery scale is elevated or scratched, bleeding points are evident (ie, Auspitz sign). In moist intertriginous areas, such as the axillae and groin, well-demarcated erythematous patches and plaques predominate.

Although psoriasis is characteristically a cutaneous condition, some clinicians believe it may uncommonly manifest on the lips, tongue, palate, buccal mucosa, and gingiva. Psoriatic tongue involvement appears indistinguishable from geographic tongue involvement. In addition, a higher frequency of fissured tongue occurs in patients with psoriasis. Pindborg recognized 3 other findings suggestive of oral psoriasis. These findings include small, whitish papules that yield bleeding points upon scraping; red and white plaques that follow skin lesions; and bright-red patches. Because oral psoriasis rarely manifests without cutaneous involvement, definitive oral diagnosis is made with the finding of corresponding cutaneous lesions and is confirmed with biopsy results.

Histologic findings demonstrate characteristic psoriatic histology: parakeratosis and hyperplasia of the epidermis; elongation of rete ridges; a thinned stratum granulosum; Munro microabscesses of neutrophils superficially; and chronic inflammation of the epidermis and the dermis with polymorphonuclear leukocytes, lymphocytes, and histiocytes. Dilated and tortuous blood vessels high in the submucosa are also noted.