Dr. Ted Rosen Highlights Oral Lesions in Dermatology

Oral lesions represent a diagnostic challenge in dermatology due to their limited morphological variation and overlapping features across conditions. At the DEF Essential Resource Meeting 2025 (DERM2025), Theodore Rosen, MD, reviewed a broad spectrum of oral pathologies, from benign pigmentations to potentially life-threatening neoplasms. He emphasized the need for biopsy and interdisciplinary care, particularly with oral surgeons, to ensure accurate diagnosis and appropriate treatment.

Oral mucosa has a limited response repertoire, Dr. Rosen said.

“You can’t rely on symptoms, location, or lesion count alone,” he said, adding that 28% of adults exhibiting some form of oral lesion.

Dr. Rosen noted that nicotine stomatitis, often mistaken for a precancerous condition, is a benign keratotic response to heat exposure, typically from smoking tobacco or cannabis. The hallmark appearance is white plaques with red punctate spots. Dr. Rosen emphasized its near-zero malignant potential, advising against unnecessary intervention.

Meanwhile, amalgam tattoos, resulting from dental fillings, appear as gray-to-black macules in the oral mucosa and can be confused with melanotic lesions. Diagnosis, Dr. Rosen said, can be confirmed via dental x-ray showing metallic fragments. In contrast, black hairy tongue—a benign elongation of filiform papillae—often results from poor oral hygiene, smoking, or antibiotic use, he said. Patients may present with black, brown, or yellow discoloration. Management involves mechanical debridement and patient reassurance.

Oral piercings involving the tongue or lip can cause complications, Dr. Rosen said, ranging from infection and allergic contact dermatitis to more severe outcomes such as aspiration or dental trauma. Dr. Rosen advised against lip piercings, noting the risk of recurrent cellulitis and mucosal damage.

Dr. Rosen noted the higher prevalence of recurrent aphthous stomatitis, a common cause of painful oral ulcers, in women and he classified lesions by size: minor (<1 cm), major (>1 cm), and herpetiform (numerous clustered ulcers). The differential diagnosis includes syphilitic mucous patches, hand-foot-mouth disease, erosive lichen planus, and Behçet syndrome. His preferred treatment is sublingual vitamin B12, which has shown up to 85% efficacy in studies. Other options include systemic corticosteroids, colchicine, or dapsone for severe or refractory cases.

Dr. Rosen noted several systemic diseases and treatments that present with distinctive oral findings:

• Behçet Syndrome: Characterized by oral and genital ulcers and ocular inflammation. Apremilast, a PDE4 inhibitor, is FDA-approved for this indication and offers sustained control.
• Neutropenic Ulcers: Occurring in immunocompromised patients, often post-chemotherapy. These are necrotic, painful, and irregular. Management centers on coordinating with oncology to adjust treatment intensity.
• Autoimmune Blistering Disorders: Mucous membrane pemphigoid (MMP) and pemphigus vulgaris (PV) may present similarly but differ histopathologically. MMP poses a risk of ocular scarring and blindness if untreated. Rituximab has dramatically improved disease control.
• Candidiasis: Beyond classic white plaques, erythematous forms (atrophic candidiasis) can present as red, burning patches—particularly under dentures or in patients on IL-17 inhibitors. Diagnosis is clinical or confirmed by scrapings; treatment includes clotrimazole troches or fluconazole (noting increasing resistance).

Dr. Rosen noted that oral lichen planus, especially the erosive subtype, carries a 1% to 2% risk of malignant transformation. He urged vigilance, particularly in patients with longstanding disease or leukoplakic changes.

Reviewing features of oral squamous cell carcinoma (SCC)—often asymptomatic unless neural invasion is present—Dr. Rosen said that concerning signs include ulceration, induration, size increase, and color variegation.

“If it’s ugly or asymmetrical, biopsy it,” he said, adding that SCC may arise in patients with pigment loss (eg, lupus scars), pipe smokers, or those with chronic trauma.

Oral melanoma, though rare, must also be considered, Dr. Rosen said. Suspicion should be high for large, darkly pigmented, irregular lesions—especially in individuals of Japanese descent, where prevalance is higher.

Toward the end of his talk, Dr. Rosen noted that mucoceles and torus palatinus are common benign entities. Mucoceles present as fluctuant, translucent swellings—typically on the lower lip—while tori are firm exostoses of the hard palate. Neither requires intervention unless symptomatic.

While many conditions are benign, Dr. Rosen emphasized that clinicians must maintain a high index of suspicion for malignancy or systemic disease. Partnership with oral surgeons and targeted use of biopsy, he said, remain foundational to high-quality care.