What Is Erythroplakia

Introduction

An individual is said to have erythroplakia if they have a fiery red patch or plaque on their oral mucosa that cannot be clinically classified as any other type of distinguishable lesion.¹ The name "erythroplakia" comes from the Greek words "erythros," which means red, and "plakia," which means plaque. Erythroplakia is one of the most alarming lesions of the oral cavity due to the high probability that it will develop into cancer.² This is despite the fact that it is a very uncommon diagnosis. In 1911, the physician Queyrat coined the term "erythroplasia of the glans penis" to characterise this illness for the first time. Oral erythroplakia was first described as a lesion of the oral mucosa by Schwimmer and Greenspan in 1953.³  They were also the ones who came up with the term.

Erythroplakia presents itself as a crimson plaque that has a velvety texture and a smooth, gleaming surface. There is very little indication of aberrant blood vessels or surface roughness on the plaque.⁴ It is well defined and typically manifests as a single lesion, most frequently affecting the floor of the mouth, the lateral tongue, the retromolar pad, or the soft palate of older adults.⁵  Due to the fact that the clinical presentation is not in itself diagnostic, confirmation must be achieved through histological examination. Erythroplakia is problematic since a high rate of dysplasia or malignant transformation is detected when it is biopsied, despite the fact that it is not a typical result when an oral examination is performed. In light of the fact that oral erythroplakia lesions are linked to an increased risk of carcinoma⁶, early detection and timely evaluation are of the utmost importance.

Epidemiology

It has been estimated that the prevalence of erythroplakia ranges from 0.005% to 0.04% in various groups that have been examined, which indicates that it is a rather unusual finding.² The true incidence of oral erythroplakia may be underestimated, however, because of its mild clinical appearance and the general lack of knowledge surrounding the condition. According to studies, the assigned male at birth (AMAB) to assigned female at birth (AFAB)  ratio ranges from 2:1 to 5:1, with a larger prevalence among older AMAB in their 6th or 7th decade of life compared to those AFAB in the same age range.³ This is consistent with the demography of oral cancer and suggests that a role may be played by a lifetime of carcinogen exposure resulting from the consumption of substantial risk factors such as tobacco, alcohol, and betel nut. The soft palate, the floor of the mouth, the ventrolateral tongue, and the area around the retromolar pads are common subsites that are affected.⁶ 

Immunosuppression and infection with high-risk strains of oral human papillomavirus both have the potential to increase a person's risk of developing erythroplakia.^8,9 According to some estimations, the malignant transition of oral erythroplakia lesions to invasive oral squamous cell carcinoma or carcinoma-in-situ happens in more than fifty percent of cases, emphasising that routine monitoring is essential.² Targeted screening of high-risk individuals, such as older people who have a chronic use of betel nuts, cigarettes, or alcohol should enable early detection and assessment of these alarming red patches before they develop into cancer.⁹ 

Clinical features 

In a clinical setting, erythroplakia presents itself as a single, well-defined patch or plaque that has a vivid red colour and a velvety texture.⁴ It is common for the surface to be smooth, shiny, and devoid of any visible roughness, keratosis, or aberrant vessels.⁵ In most cases, the borders are not regular, but they may occasionally take the form of a defined margin. The diameter can fluctuate anywhere from just a few millimetres to several centimetres⁶, making it possible for the size to be rather variable. The most common sites of involvement are the floor of the mouth, the tongue, the soft palate, and the pad behind the back teeth.² 

Unless cancer has formed within or beneath the erythroplakia lesion³, the symptoms of erythroplakia are typically very mild. Patients who are experiencing this condition may describe the affected area as aching, painful, numb, or indurated. During the clinical inspection, it is important to carefully palpate the area in question to determine its thickness or induration. It is anticipated that progression to oral squamous cell carcinoma or carcinoma-in-situ occurs in more than fifty percent of persistent erythroplakia lesions that are not treated, which is why lifelong monitoring is vital for the early diagnosis of any malignant transformation.¹⁰ Due to the insidious nature of the natural progression of oral erythroplakia, a biopsy is required for any red patch that cannot be explained and is resistant to the removal of irritants.

Histopathology

Given the absence of distinguishing clinical characteristics, a diagnosis of erythroplakia can only be confirmed by the use of microscopic examination.⁴ Histologically, erythroplakia is characterised by a reduction in the thickness of the epithelial layer, as well as a loss of rete ridges and disorganisation of the epithelium.¹ The surface architecture is noted to be flattened, but there is no synthesis of keratin like that seen in leukoplakia.⁵ 

On hematoxylin and eosin staining, dysplastic alterations are seen. These changes include cellular pleomorphism, nuclear hyperchromasia, an elevated nuclear-cytoplasmic ratio, aberrant mitoses, and loss of polarity.¹⁰ The extent of architectural disruption and cytologic atypia can determine the severity of epithelial dysplasia, which can range from mild to severe.¹¹ A biopsy of erythroplakia lesions can also detect carcinoma-in-situ, as well as full-thickness dysplasia and invasive islands of squamous cell carcinoma.⁶  Erythroplakia lesions are characterised by a reddish-brown colour.

It is crucial to obtain a confirmation tissue diagnosis for any clinically suspected erythematous oral lesions due to the high risk of malignant transformation. This can be done by obtaining a biopsy of the lesion. A biopsy is essential for excluding the possibility of cancer and determining the most appropriate course of treatment based on the degree of dysplasia seen under the microscope. It may be necessary to perform repeated biopsies over the course of time in order to monitor the progression of the disease.

Management

Due to the increased risk of cancer, erythroplakia should be treated with an emphasis on early detection and confirming biopsies.¹² Even if the erythematous patch appears to be clinically harmless, a scalpel biopsy should be performed on it if it is persistent and resistant to the removal of irritants.¹ To acquire sufficient epithelium for histological examination, an incisional or brush biopsy is recommended whenever possible. Due to the possibility of progression, close endoscopic monitoring at intervals of three to six months must be performed if there is evidence of mild to moderate dysplasia.¹¹ 

In cases of carcinoma-in-situ or localised superficially invasive oral squamous cell carcinoma, an excisional surgery with margins of 1-2 millimetres is recommended.¹³ It may be necessary to do segmental resection and a neck dissection on more advanced or poorly defined lesions, depending on the thickness of the tumour and the lymph node involvement.¹⁴ According to the stage of the malignancy, adjuvant treatment with radiation and/or chemotherapy may be necessary. The use of photodynamic therapy as a non-surgical treatment option for superficial premalignant erythroplakia lesions¹⁵ is gaining popularity as a promising treatment option. In light of the fact that therapy can result in a field cancerisation effect, patients should continue their routine screenings for oral cancer and abstain from using tobacco, alcohol, and other cancer-causing substances.

Prognosis

The stage of erythroplakia that was present at the time of diagnosis and therapy has a direct correlation with the patient's prognosis. Erythroplakia lesions that are excised early while they are still benign or carcinoma-in-situ lesions that are restricted to the epithelial layer have excellent outcomes, with a 5-year survival rate that is greater than 90%.⁹ However, if invasive cancer develops and spreads into deeper tissues, the prognosis becomes much worse.¹⁶ There is a poor prognosis associated with the existence of perineural or vascular invasion, inadequate resection margins, the extent of local tumour invasion, the development of regional lymph node metastases, and inadequate resection margins.¹⁷ 

It is predicted that persistent erythroplakia that is not treated has malignant transformation rates that are higher than fifty percent, which indicates that continuous lifelong monitoring is essential for the early detection of neoplastic alteration.² Erythroplakia lesions can be detected through the use of public awareness campaigns and screening programmes aimed at older persons who use tobacco, betel nuts, or alcohol. This enables more timely diagnosis and treatment. Early diagnosis, in conjunction with histopathologic verification, provides the highest opportunity for survival as well as the maintenance of oral function. However, due to the idea of field cancerisation and the possibility of secondary primaries¹⁸, it is imperative to do follow-up over an extended period of time. 

Summary

Erythroplakia is one of the most concerning oral cavity lesions because it has a high risk of developing into cancer; however, it is a rare diagnosis. It usually appears as a single lesion that can vary in size and has a vivid red colour and velvety texture. The most common areas of involvement are the mouth floor, tongue, soft palate, and pad behind the back teeth. Unless cancer has developed within or beneath the erythroplakia lesion, the symptoms are usually very mild. Patients who have this condition may describe the affected area as aching, painful, numb, or indurated. A histological examination can confirm the diagnosis of erythroplakia. Early detection and timely evaluation are important as oral erythroplakia lesions are linked to an increased risk of carcinoma, especially in high-risk individuals, such as older people who have chronic use of betel nuts, cigarettes, or alcohol.