Open Access Case

Report DOI: 10.7759/cureus.5204

A Rare Case of Intraoral Psoriasis

Divyambika C. Venugopal 1 , Sathasivasubramanian S 1 , Malathi Narasimhan 2

1. Oral Medicine and Radiology, Faculty of Dental Sciences, Sri Ramachandra Institute of Higher
Education and Research, Chennai, IND 2. Oral Pathology, Faculty of Dental Sciences, Sri Ramachandra
Institute of Higher Education and Research, Chennai, IND

 Corresponding author: Divyambika C. Venugopal, cvdivyambika@sriramachandra.edu.in

Disclosures can be found in Additional Information at the end of the article

Abstract
Psoriasis is a chronic inflammatory mucocutaneous disease predominantly affecting the skin.
While oral manifestations are common in many papulosquamous conditions, the occurrence of
oral lesions in psoriasis is relatively rare. This case report highlights the presence of oral
lesions in cutaneous psoriasis and the need for early identification of such lesions for timely
management and better symptomatic improvement.

Categories: Dermatology, Miscellaneous

Keywords: psoriasis, mucocutaneous, papulosquamous

Introduction
Psoriasis is a commonly documented skin disorder with a clinical presentation of papules and
plaques covered with white scales. However, the intraoral presentation of psoriasis, either
coexisting with cutaneous lesions or presenting as isolated oral lesions, is rarely reported in
the literature [1]. Among the various clinical presentations involving the skin, the plaque type is
more common, followed by guttate, pustular, inverse, and erythrodermic types [2]. The most
commonly reported oral manifestations are erythema migrans, gingival erythema, psoriatic
arthritis of the temporomandibular joint, and, very rarely, psoriatic mucositis affecting buccal
mucosa and palate [3,4]. A review by Brooks shows evidence of an increased risk for an array of
systemic disorders in the presence of cutaneous psoriasis and emphasizes the need for a
thorough evaluation of systemic comorbidities for successful clinical outcomes [3].

Case Presentation
A 56-year-old male patient reported to the Department of Oral Medicine and Radiology, with a
chief concern of an oral burning sensation on consuming spicy foods lasting three weeks. The
patient’s history was significant for cutaneous psoriasis on the right nape of the neck and nail
Received 06/01/2019
Review began 07/02/2019
beds, being treated with medication. He reported symptomatic improvement with respect to
Review ended 07/15/2019 cutaneous psoriasis following treatment. Intraoral examination revealed well-defined linear
Published 07/22/2019 whitish plaque over the right and left buccal mucosa, surrounded by erythematous areas and
© Copyright 2019
multiple erythematous lesions in relation to the maxillary and mandibular labial mucosa. The
Venugopal et al. This is an open whitish plaque was non-scrapable and non-tender (Figure 1)
access article distributed under the
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How to cite this article

Venugopal D C, S S, Narasimhan M (July 22, 2019) A Rare Case of Intraoral Psoriasis. Cureus 11(7):
e5204. DOI 10.7759/cureus.5204
 FIGURE 1: Intra-oral lesion on the right (A) and left (B) buccal
mucosa

The results of the patient’s hematological investigations were unremarkable. An incisional

biopsy was performed, and the histopathological examination revealed the presence of
parakeratotic stratified squamous epithelium with acanthosis alternating with atrophic
epithelium with a focal area of liquefactive degeneration of basal test tube-shaped rete ridges
(Figures 2, 3)

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 FIGURE 2: 10X view showing parakeratotic stratified squamous
epithelium with test-tube shaped rete ridges

2019 Venugopal et al. Cureus 11(7): e5204. DOI 10.7759/cureus.5204 3 of 8

 FIGURE 3: 40X view showing liquefactive basal cell
degeneration with test-tube shaped rete ridges

The underlying connective tissue showed focal areas of juxta epithelial hyalinization along
with chronic inflammatory cell infiltration and increased vascularity (Figures 4, 5).

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 FIGURE 4: 10X view showing papillomatous hyperplasia with
juxta epithelial inflammatory cell infiltration

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 FIGURE 5: 40X view showing Munro’s abscess

The patient was advised topical steroids (triamcinolone acetonide 0.1%) twice per day for 15
days. He was relieved of the burning sensation but was ultimately lost to follow-up.

2019 Venugopal et al. Cureus 11(7): e5204. DOI 10.7759/cureus.5204 6 of 8

 Discussion
Psoriasis is a chronic inflammatory disorder, predominantly affecting the skin, and has been
one of the oldest documented skin lesions [5]. Oral manifestations of psoriasis are relatively
rare, which may be due to the more rapid epithelial regeneration in the oral cavity as compared
to the skin [5]. The first case of oral psoriasis was reported by Oppenheim in 1903, where the
patient had presented with well-demarcated yellowish-white plaques, subsequently confirmed
by biopsy [6]. Some of the oral manifestations previously reported include geographic
stomatitis and fissured tongue (occurring in 10% of patients with skin manifestations) [5].

Unlike skin lesions, oral lesions do not have a regular pattern and varied presentations include
small, whitish papules that produce bleeding points on scraping; red and white plaques that
mimic dermal presentation; and bright red or white patches ranging in severity, sometimes
with a simultaneous presentation of angular cheilitis [7,8]. The present case had a bilateral
presentation of non-scrapable atypical lesions and white plaque surrounded by erythematous
areas with multiple erythematous lesions in the maxillary and mandibular labial mucosa, which
did not fit into similar recognized white lesions. Some guidelines indicate that oral psoriasis
diagnosis should only be made in the presence of concomitant skin lesions [5]. However,
isolated cases of oral psoriasis have been documented [9,10]. Our patient was undergoing
treatment for guttate psoriasis of the skin. Hence, correlating skin lesions with histological
findings from oral biopsy favored the final diagnosis of oral psoriasis. Treatment usually aims
for symptomatic improvement [5]. The mainstay of treatment includes topical and systemic
steroids, immunomodulators such as cyclosporine and tacrolimus. Patients have shown
symptomatic improvement and regression of oral lesions following topical application of
topical corticosteroids [7,9]. As per the US guidelines on the management of psoriasis, topical
corticosteroids are commonly used in the management of psoriasis either as a single agent
therapy in case of mild to moderate disease or in combination with systemic steroids in severe
disease to maximize control and minimize side effects [11]. The topical corticosteroids are
commonly used in painful oral inflammatory conditions such as erosive lesions of the oral
mucosa [12]. Oral psoriasis has been successfully managed with topical steroids with complete
remission [9,10]. Despite being on a low dose of systemic steroids, our patient experienced
symptomatic improvement with a reduction in the burning sensation and regression of oral
lesions only after topical application of triamcinolone acetonide, which highlights the role of
topical steroids in successful management of such erosive conditions.

Conclusions
This case highlights an atypical presentation of oral psoriasis coexisting with cutaneous
psoriasis. Obtaining an accurate medical history along with a thorough evaluation aids in the
early identification of the condition, thus facilitating the prompt institution of treatment for
better clinical outcomes.

Additional Information
Disclosures
Human subjects: Consent was obtained by all participants in this study. Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared
that they have no financial relationships at present or within the previous three years with any
organizations that might have an interest in the submitted work. Other relationships: All
authors have declared that there are no other relationships or activities that could appear to
have influenced the submitted work.

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