Verrucal Lesions
Master the INBDE with Dental Panda: Your go-to resource for expert practice exams and tailored study resources!
CONDYLOMA ACUMINATUM
Condyloma Acuminatum is an infectious sexually transmitted disease associated with exposure to human papillomavirus (HPV types 6, 11, 16, and 18). The genome of HPV contains oncogenes that encodes proteins capable of inducing differentiated squamous epithelial proliferation. The common clinical presentation includes:
- Solitary or multiple wart-like lesions located at the site of contact.
- Pink to whitish-pink, exophytic papillary growths with pedunculated outline.
- Usually involves non-keratinized tissues in immunocompetent patients.
Polymerase chain reaction should reveal the specific HPV subtypes. Electron microscopy demonstrates intranuclear virions. Diagnosis is based on the lesion history and clinical presentation only. If a biopsy is performed microscopic findings may include:
- Koilocytotic cellular changes (large keratinocytes with abundant cytoplasm).
- Papillomatosis-type hyperplasia.
You differential diagnosis should include:
- Focal epithelial hyperplasia.
- Lichen planus.
- Intraoral verruca vulgaris.
- Squamous papilloma.
Treatment options include:
- Conservative removal (surgery, laser ablation, cryotherapy).
- Topical podophyllin or imiquimod.
Recurrence is common.
KERATOACANTHOMA
Keratoacanthoma is a rapidly growing well-differentiated dome-shaped skin tumor with a centralized keratinous plug. Historically it has been considered a highly differentiated variant of cutaneous squamous cell carcinoma, sharing clinical and histopathological features. Risk factors for keratoacanthoma include UV exposure, human papillomavirus (HPV 11, 13, 24, 33, 57) exposure, chemical carcinogens, immunosuppression, and trauma. The common clinical presentation includes:
- Solitary lesion on sun-exposed areas (lip).
- Early lesion – erythematous papule with rapid initial period of growth (4-8 weeks).
- Mature lesion – hemispheric firm nodule with central keratin plug.
- Occasionally regresses spontaneously.
Diagnosis is based on the lesion history, clinical presentation and microscopic findings, which may include:
- Normal proliferation of well-differentiated keratinocytes.
- Multilobular exophytic or endophytic cyst-like invagination of the epidermis.
- Central horn plug of keratin.
- No invasion.
- Marked pseudoepitheliomatous hyperplasia.
Your differential diagnosis should include:
- Squamous cell carcinoma.
- Verruca vulgaris.
- Condyloma acuminatum.
- Squamous papilloma.
Treatment options include:
- No treatment, careful observation.
- Many are surgically removed due to risk of squamous cell carcinoma.
- Cryotherapy.
- Intralesional chemotherapy (methotrexate, 5-fluorouracil, or bleomycin).
LYMPHANGIOMA
Lymphangioma is an uncommon, benign congenital malformation of the lymphatic tissue that can be seen anywhere on the skin and mucous membranes. The common clinical presentation includes:
- Superficial or deep lesion that waxes and wanes in size.
- Superficial mucosal lymphangiomas resemble caviar or frog’s eggs.
- Most commonly involves the tongue, followed by lips, buccal mucosa, and palate.
- May cause facial asymmetry.
- Deeper lesions present as painless fluctuant masses that can cause macroglossia.
Diagnosis is based on the lesion history, clinical presentation, lymphangiography and microscopic findings, which may include:
- Collections of large lymphatic cisterns.
- Dilated dermal lymphatic channels lined with endothelial cells.
- Overlying epidermis is usually acanthotic or hyperkeratotic.
- No atypical vascular features, nuclear atypia, mitotic activity, or koilocytic changes.
You differential diagnosis should include:
- Neurofibroma.
- Hemihypertrophy syndromes.
Treatment options include:
- Simple observation if the lesion is large, stable, or asymptomatic.
- Surgical removal.
- Sclerotherapy.
PAPILLARY HYPERPLASIA
Papillary Hyperplasia is a benign nodular lesion of the palatal mucosa usually found in patients with an ill-fitting maxillary prosthesis or patients who exhibit poor denture cleaning or wearing habits (24/7 wearing). Concomitant candida infection is likely. The common clinical presentation includes:
- Erythematous palatal tissue beneath maxillary prosthesis.
- Pink to red nodular papillary growth.
- Generally asymptomatic.
Diagnosis is based on the lesion history, clinical presentation, and microscopic findings, which may include:
- Papillary projections covered by stratified squamous epithelium.
- Fibrous and epithelial papillary hyperplasia with or without chronic inflammation.
Your differential diagnosis should include:
- Contact stomatitis.
- Candidiasis.
- Denture stomatitis.
Treatment options include:
- Promote good oral hygiene.
- Antifungal therapy if necessary.
- Surgical removal of excessive affected mucosa if necessary.
- Denture reline or remake.
SQUAMOUS PAPILLOMA
Squamous Papilloma is a common benign exophytic growth of the soft tissues caused by epithelial proliferation induced by human papillomavirus (HPV 6 and 11). The genome of HPV contains oncogenes that encodes proteins capable of inducing differentiated squamous epithelial proliferation. Though rare, malignant transformation is possible. The common clinical presentation includes:
- Asymptomatic exophytic polyps with a wart-like shape.
- Appears pedunculated, sessile or verrucous (depending on the location).
- Usually a solitary white lesion, but may find multiple.
- The most commonly affected area is the palate, followed by the uvula, tongue, gingiva, and buccal mucosa.
Diagnosis is based on the lesion history, clinical presentation, and microscopic findings, which may include:
- Epithelial hyperplasia with fibrovascular cores.
- Finger-like papillary projections that may be sharp to blunt.
- Koilocytotic cellular changes (large keratinocytes with abundant cytoplasm).
- Epithelium may become dysplastic.
You differential diagnosis should include:
- Condyloma acuminatum.
- Verruca vulgaris.
- Focal epithelial hyperplasia.
- Verrucous carcinoma.
- Lymphoma or lymphoepithelioma.
Treatment usually involves surgical excision and the recurrence rate is low.
VERRUCA VULGARIS
Verruca Vulgaris (common wart) is a common benign exophytic growth of the soft tissues caused by epithelial proliferation induced by human papillomavirus (HPV 2, 4, 6, or 11). The genome of HPV contains oncogenes that encodes proteins capable of inducing differentiated squamous epithelial proliferation. Transmission is by direct contact and the virus exclusively infects epithelial cells of the skin or mucous membranes. The common clinical presentation includes:
- Papular to nodular exophytic appearance.
- Cauliflower-like surface texture.
- Oral mucosal lesions are usually white to pink. Perioral skin lesions may be brownish.
- Pedunculated or broad based.
- Multiple oral lesions may be evident in immunocompromised patients.
Diagnosis is based on the lesion history, clinical presentation, and microscopic findings, which may include:
- Surface hyperkeratosis and granulosis.
- Koilocytotic cellular changes (large keratinocytes with abundant cytoplasm).
- Immunohistochemical demonstration of HPV common antigen.
You differential diagnosis should include:
- Focal epithelial hyperplasia.
- Keratoacanthoma.
- Papillary squamous carcinoma.
- Squamous papilloma.
- Condyloma acuminatum.
Treatment usually involves conservative removal (surgery, laser ablation, cryotherapy). Recurrence is common.
VERRUCOUS CARCINOMA
Verrucous Carcinoma is a rare slow growing variant of squamous cell carcinoma that presents as a well-differentiated, exophytic and endophytic mucocutaneous malignancy. Risk factors include tobacco use (especially smoke-less tobacco) and HPV infection. The common clinical presentation includes:
- Early lesion – grayish-white or red keratotic patch interpreted as verrucous hyperplasia.
- Mature lesion – exophytic, irregular, and indurated.
- Advanced lesions may spread into adjacent tissues (periosteum, bone) but there is little metastatic potential.
Diagnosis is based on the lesion history, clinical presentation, and microscopic findings, which may include:
- Well-differentiated blunt masses of hyperplastic epithelium extending into submucosa.
- Ingrowth helps to differentiate it from benign verrucous growths.
- Abundant keratin leading to exophytic “church-spire” keratosis with bulbous rete ridges.
- Well-differentiated with minimal or no pleomorphism of cells.
Your differential diagnosis should include:
- Verrucous hyperplasia.
- Papillary squamous cell carcinoma.
- Proliferative verrucous leukoplakia.
Treatment options include:
- Surgical excision with adequate margins (wide excision for advanced lesions).
- Radiation therapy.
