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Erythroplakia  

Erythroplakia is defined as a fiery red patch that cannot be characterized either clinically or pathologically as any other definable lesion .These may appear as smooth, velvety, granular or nodular lesions often with a well-defined margins adjacent to normal looking mucosa.The soft palate, the floor of mouth, the ventral surface of tongue and the retromolar area are the most common sites of involvement . Erythroplakia is more common among middle aged to elderly persons and, especially among men . The prevalence of these lesions range from 0.02-0.83% in different regions . Erythroplakia is strongly associated with tobacco habits and alcohol drinking(52;53). The risk factors for erythroplakia are the same as for oral squamous cell carcinoma.

Diagnosis:

Erythroplakia is seldom multicentric and rarely covers extensive areas of the mouth. It is soft on palpation and does not become indurated until an invasive carcinoma develops in it . It is often asymptomatic, although some patients may complain of a sore, burning or metallic sensation. Oral erythroplakia has the highest risk of malignant transformation compared to all other mucosal lesions. Histological examination of clinically diagnosed erythroplakia often shows severe epithelial dysplasia, carcinoma in-situ or micro-invasive cancer .

All erythroplakias should be viewed with extreme clinical suspicion for malignancy, as they are more likely to harbour histological foci of severe dysplasia, carcinoma in-situ (CIS) or invasive cancer. We advise excision biopsy and histological examination as a mandatory procedure whenever an erythroplakia is clinically diagnosed.

Histopathology:

Erythroplakia harbours carcinoma in about 51% of cases, severe dysplasia or CIS in 40% and mild to moderate dysplasia in 9% . The red appearance is due to the thin atrophic epithelium with prominent subepithelial vascularity and inflammation. Almost all erythroplakic lesions contain dysplastic cells. The histopathology may be mild or moderate epithelial dysplasia, severe dysplasia or carcinoma in-situ. Carcinoma in-situ is characterized by a complete disorganization of cells throughout all layers of the epithelium, with no keratin pearls. In other words, the entire thickness of the epithelium is occupied by dysplastic cells, with an intact and well-defined basement membrane. Rete pegs are frequently bulbous or tear-drop shaped, often with secondary proliferations or projections of abnormal cells. Nuclei are typically hyperchromatic and enlarged, with the amount of cytoplasm diminished. Mitotic activity is pronounced and abnormal mitotic figures may be noted. The basement membrane should be carefully examined for areas of micro-invasion.

Differential diagnosis:

The following conditions should be considered before making a diagnosis of erythroplakia:

• Non-homogeneous leukoplakia
• Erosive lichen planus
• Acute atrophic candidiasis
• Invasive oral cancer
• Pemphigus
• Lupus erythematosus
• Denture induced stomatitis
• Haemangioma

Management:

Management of oral erythroplakia focuses on the prevention of malignant transformation and early detection of occult malignancy. Persons with erythroplakia should be advised to stop tobacco/alcohol habits, and should be encouraged to take a diet rich in vegetables and fruits. In view of the high malignant potential of these lesions the recommended treatment is surgical excision, including laser . However, even after surgical excision, the recurrences and development of malignancy at the same site are high . In view of this, long-term follow-up is essential even after surgical removal.

Image	Caption
	Figure 1: Erythroplakia. A 53-year-old heavy smoker with 2x3 cm erythematous lesion (arrow) on the left side of the posterior aspect of the hard palate.
	Figure 2: Erythroplakia. Note the red patch on the right buccal mucosa with white areas posteriorly.
	Figure 3: Oral submucous fibrosis with erythroplakia of the tongue.
	Figure 4: Erythroplakia. Note the red velvety lesion involving the posterior aspect of the right side of the hard palate. Note the raised irregular area along the anterolateral aspect of the lesion which is clinically suspicious of malignant transformation.