DISCUSSION
B. Verruca vulgaris (VV).
VV is a benign hyperplasia of stratified squamous epithelium and,
like SP, is an HPV-driven process. The most common HPV type
involved in the pathogenesis of VV is type 2. VV is a very common
skin lesion, especially in children (average age 13), although it can
develop at any age. A slightly higher predilection for girls has been
reported.4 The lesion is considered contagious. It can spread by
auto-inoculation, as well as spread to others via direct contact.
Oral lesions are rare in comparison to skin lesions, and in comparison
to oral SPs. When it does present intraorally, VV s most commonly
found on the labial mucosa, vermilion border, or anterior tongue.2
VV can present as a solitary lesion, or multiple lesions may develop.
It is not uncommon for clusters of lesions to be present. VV most
commonly presents as a painless, exophytic growth with finger-like
papillary projections, or it may exhibit a pebbly, rough surface.
Lesions can be painful if they are located in an area that is easily
irritated.4 VV can be either sessile or pedunculated, and the color
can vary from white or pink, to yellowish. Oral lesions are almost
always well-keratinized and white in appearance. The lesion can
exhibit rapid growth to its maximum size, which is usually less
than 5mm in diameter. Once it has reached its maximum size, the
lesion usually remains unchanged in size, unless irritated.2 When
irritated, the lesion may grow. Histologically, VV contains papillary,
finger-like projections with underlying connective tissue cores that
may resemble SP. (Figure 4a and 4b) However, VV shows epithelium
that is hyperkeratotic with alternating para- and orthokeratin and
a prominent granul ar cell layer on H&E stain. The rete ridges of
the epithelium are elongated and converge towards the center,
producing a characteristic “cupping” effect.5 Koilocytes are often
noted in the superficial epithelium. Eosinophilic intranuclear viral
inclusions may also be noted in the granular cell layer.2 A chronic
inflammatory infiltrate may or may not be seen in the underlying
connective tissue.
Treatment of cutaneous lesions involves topical medications, such
as salicylic acid, lactic acid, or cryotherapy using liquid nitrogen.
Salicylic acid is the most effective; however it is slow to work and
requires frequent applications, for up to 12 weeks.6 Cryotherapy is
successful 50-70 percent of the time.6 Oral lesions are most often
treated with surgical excision that should include the base of the
lesion. Alternative treatment methods have also been tried with
varying degrees of success, including intralesional immunotherapy,
intralesional bleomycin or 5-fluorouracil, and photodynamic therapy.
Combination therapy is a more effective approach in many cases.4
Recurrence can occur in a small percentage of treated cases.
VV has not been reported to undergo malignant transformation.
If left alone, up to two-thirds of cutaneous lesions will actually
spontaneously regress within two years. Spontaneous resolution is
more commonly seen in children.2 In the present case, the lesion
was located in the oral cavity, which placed VV lower on the list
of differentials, since the lesion is relatively rare intraorally.
Additionally, the patient had no reported history of skin VV.
The lesion in our case was solitary and relatively large, also
favoring an SP over a VV. However, VV should be considered in
the differential diagnosis.
C. Condyloma acuminatum (CA).
CA is a common, benign, HPV-induced, sexually-transmitted lesion
that occasionally presents in the oral cavity. Overall, CA affects
about 1 percent of the sexually active population.2 CA presents
more commonly in the anogenital region, but it can be seen in the
mouth and the larynx. In some cases, it may be difficult to detect
intraorally.7 Ninety percent of CAs are caused by HPV types 6 and
11.2 The virus has an incubation period of 1-3 months before a
clinically apparent lesion develops, but it can remain dormant for
longer periods.8 When seen in young children, they may be an
indicator of abuse or may be due to vertical transmission through
the birth canal in an infected mother. Nearly one half of the new
infections occur in those 15-24 years old, but it can present in all
age groups.8 It should be noted that the introduction of the HPV
vaccine has dramatically reduced the incidence of CA in adolescents
and young adults.7 The most common intraoral sites are the labial
mucosa, lingual frenum, and soft palate. Lesions are frequently
multiple and clustered. CA presents as a pink, sessile, non-tender,
exophyic, well-demarcated mass with short blunted surface
projections. Lesions can range in size from 1.0 to 3.0cm.2 Histologically,
CA presents with papillary projections that are more broad and
Figure 4A and 4B:
(H&E, 200x and 100x): Hyperparakeratinized finger-like
projections with fibrovascular cores seen in a SP.
It does not show alternating orthokeratinization and
parakeratinization, as seen in VV.
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N O V / D E C 2 0 1 6 | P E N N S Y LVA N I A D E N TA L J O U R N A L