Oral Hairy Leukoplakia


Oral hairy leukoplakia (OHL) is an oral infection caused by Epstein-Barr virus (EBV). It appears as white corrugated lesions (sometimes "hairy" in appearance) primarily on the lateral aspects of the tongue. The infection may spread across the entire dorsal surface onto the ventral surface of the tongue, and occasionally may be found on buccal mucosa. It is common in people with HIV infection, particularly in those with advanced immunosuppression (CD4 count <200 cells/µL), and may serve as a marker of HIV.

S: Subjective

The patient notices new, white lesions on the tongue that cannot be wiped off or removed by scraping or brushing. The OHL lesions usually are asymptomatic, but occasionally may cause alteration in taste, discomfort, or other symptoms.

O: Objective

Perform a focused examination of the oropharynx. OHL appears as unilateral or bilateral white plaques or papillary lesions on the lateral, dorsal, or ventral surfaces of the tongue or on buccal mucosa. The lesions may vary in appearance from smooth, flat, small lesions to irregular, "hairy" or "verrucous" lesions with prominent vertical folds or projections.

A: Assessment

A partial differential diagnosis for OHL includes:

  • Oral candidiasis
  • Squamous cell carcinoma
  • Geographic tongue
  • Lichen planus
  • Smoker's leukoplakia
  • Epithelial dysplasia
  • White sponge nevus
  • Irritation leukoplakia

P: Plan

Diagnostic Evaluation

A presumptive diagnosis of OHL usually is made on the basis of the clinical appearance of the lesions. OHL often is confused with candidiasis; the diagnosis of OHL should be considered for lesions that do not wipe away, as would be the case for pseudomembranous candidiasis. Definitive diagnosis of OHL requires biopsy and demonstration of EBV.

  • Perform biopsy of lesions only if they are ulcerated or unusual in appearance, to distinguish OHL from cancer or other causes.


  • Because OHL usually is asymptomatic, specific treatment generally is not necessary.
  • Immune system reconstitution through antiretroviral therapy will resolve OHL; encourage initiation of HIV treatment if the patient is not yet on antiretroviral therapy.
  • If specific treatment is required, the following options may be considered. Relapse is common after discontinuation of treatment.
    • Acyclovir 800 mg PO 5 times per day for 2 weeks; famciclovir and valacyclovir may be considered.
    • Topical tretinoin (Retin-A) 0.025-0.05% solution, podophyllin 25% in tincture of benzoin, and other treatments also have been used.
    • For relapse of severe OHL, consider maintenance therapy with high-dose acyclovir, famciclovir, or valacyclovir.
  • For severe symptomatic cases, surgical treatment (e.g., cryosurgery, excision) may provide temporary resolution.
  • Candidiasis may be present concurrently; treat candidiasis if it is present (see chapter Candidiasis, Oral and Esophageal).

Patient Education

  • Advise patients that OHL rarely is a problem in itself, but may be a marker of HIV progression.
  • Encourage patients to start antiretroviral therapy.
  • Advise patients to contact their care providers if new symptoms develop.
  • Instruct patients to comply with regular dental and medical care regimens.


  • Agbelusi GA, Wright AA. Oral lesions as indicators of HIV infection among routine dental patients in Lagos, Nigeria. Oral Dis. 2005 Nov;11(6):370-3.
  • Coogan MM, Greenspan J, Challacombe SJ. Oral lesions in infection with human immunodeficiency virus. Bull World Health Organ. 2005 Sep;83(9):700-6.
  • Greenspan JS, Greenspan D. Oral Complications of HIV Infection. In: Sande MA and Volberding PA, eds. Medical Management of AIDS, 6th ed. Philadelphia: WB Saunders; 1999:157-169.
  • Kufe DW, Pollock RE, Bast RC Jr., et al., eds. Cancer Medicine, 6th ed. Lewiston, NY: BC Decker Inc.; 2003.
  • Shiboski CH, Patton LL, Webster-Cyriaque JY, et al.; Oral HIV/AIDS Research Alliance, Subcommittee of the AIDS Clinical Trial Group. The Oral HIV/AIDS Research Alliance: updated case definitions of oral disease endpoints. J Oral Pathol Med. 2009 Jul;38(6):481-8.

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Abbreviations for Dosing Terminology

twice daily
twice weekly
intramuscular (injection), intramuscularly
intravenous (injection), intravenously
oral, orally
Q2H, Q4H, etc.
every 2 hours, every 4 hours, etc.
every morning
once daily
every hour
every night at bedtime
four times daily
every other day
every evening
three times daily
three times weekly