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White Plaques on the Cheeks

Case Challenge Number: 75

Diagnostic Information

History of Present Illness Amy is a 9-year-old-female who was referred by her pediatrician for evaluation of asymptomatic white lesions on her buccal mucosa. Her parents have been aware of Amy’s condition since early childhood. Her father and younger sibling have similar lesions. No specific diagnosis has ever been established. Amy has no complaints related to the involved areas. She is healthy, has shown normal growth and development, and has done well in school. An incisional biopsy was performed to establish a definitive diagnosis. Medical History - Pertinent medical history: no significant medical history; routine pediatric care; vaccinations are current

- Medications: daily children’s vitamins

- Adverse drug affects: none

- Pertinent family history: maternal: obesity, social drinker; paternal: smoker, social drinker; sibling: healthy younger brother

- Social history: lives with biological mother, father, and brother Clinical Findings Examination reveals a healthy, alert, well-nourished 9-year-old-female. Extra-oral examination shows normal facial symmetry. No skin, hair, or nail changes are seen. The conjunctivae appear normal. Cranial nerve function is intact. No lymphadenopathy or cervical masses are noted on palpation of the neck. Intra-oral examination shows bilateral ragged thick fissured white plaques involving the buccal mucosa bilaterally. No areas of ulceration are seen. No other mucosal lesions are seen. The dentition is in good repair. Occlusal development is in the mixed dentition stage and appears appropriate for her age. Temporomandibular joint function is normal. The patient has a lip licking habit with slight exfoliative cheilitis. An incisional biopsy of the left buccal mucosa was performed under local anesthesia.

Case Challenge 75 - Content - Diagnostic Information - Figure 1
Case Challenge 75 - Content - Diagnostic Information - Figure 2

Figures 1 & 2. Clinical examination reveals roughened thick fissured areas of leukoplakia on the right and left buccal mucosa.

Histopathologic Findings Microscopic examination of the incisional biopsy shows hyperplastic surface mucosal epithelium with elongated rete ridges, acanthosis, and thick irregular hyperparakeratosis (Figures 3 and 4). The epithelial cells in the spinous layer display cytoplasmic clearing and perinuclear eosinophilic cytoplasmic condensation (Figure 5). Surface bacterial overgrowth is present.

Case Challenge 75 - Content - Diagnostic Information - Figure 3
Case Challenge 75 - Content - Diagnostic Information - Figure 4

Figures 3 & 4. Low and medium power microscopic images showing hyperplastic squamous epithelium with elongated rete ridges, acanthosis, cytoplasmic clearing, thick ragged hyperparakeratosis, and surface bacterial colonization.

Case Challenge 75 - Content - Diagnostic Information - Figure 5

Figure 5. High-power microscopic image showing epithelial cells with pink to eosinophilic perinuclear cytoplasmic condensation and cytoplasmic clearing.