Symptoms of Oral Hairy Leukoplakia (OHL)

Oral Lesions Can be Indicative of HIV Disease Progression

Oral hairy leukoplakia (OHL). Photo Credit: U.S. Centers for Disease Control and Prevention

Hairy leukoplakia (also known as oral hairy leukoplakia, or OHL) is a commonly seen oral lesion in immune-compromised individuals, which manifests with white patches on the side of the tongue and a characteristic "hairy" appearance. It is one of several oral diseases that can regularly affect people with HIV, most often when a person's CD4 count drops below 200 cells/mL.

OHL is caused by the Epstein Barr virus (EBV), a virus of the herpes family that affects almost 95% of the population, although most will develop an adaptive immunity that prevents the virus from actively manifesting. However, in people with HIV, the diminished immune function associated with infection allows OHL the opportunity to thrive. As such, it is considered an HIV-associated opportunistic infection (OI).

OHL lesions are benign and do not cause any other symptoms. Rather, the condition is indicative of both a person’s diminished immune defense and increased susceptibility to other, more serious OIs. Generally speaking, OHL appears more often in men than in women, and is rarely seen in children.  

Prior to the advent of antiretroviral therapy (ART), OHL was strongly predictive of progression to late-stage disease, wherein as many as 47% progressed from HIV to AIDS within the course of two years. Today, with the earlier initiation of ART, the incidence of OHL has dropped significantly, unlike other HIV-associated oral infections which are more robust and present at higher CD4 levels.

Meanwhile, more recent research has also shown that smoking, in association with a low CD4 count, results in nearly a two-fold increase in the risk of OHL.

Diagnosis, Treatment and Prevention of OHL

OHL lesions vary in size. The can present on either one or both sides of the tongue or on the inside the cheek. They are not usually painful unless there is a secondary, underlying infection.

At times, the lesions may appear flat, making it more difficult to differentiate from other, similar infections. However, unlike oral candidiasis (thrush), OHL cannot be readily scraped from the tongue. This, along with the lesion's namesake appearance, are the characteristics most suggestive of OHL in people with HIV.

While clinical inspection is often enough to support a positive diagnosis, some studies suggest that up to 17% of visual examinations are incorrect.  If needed, a definitive diagnosis can be made with the microscopic examination of a biopsy and other diagnostic techniques to confirm EBV infection.

Because the OHL lesion is benign, no treatment is generally required. However, in some—particularly those with deteriorating CD4 counts—high-dose Zovirax (acyclovir) may help resolve the condition. Even so, OHL recurrence is high once the acyclovir therapy is stopped unless immune function is significantly restored.

OHL may also recur when HIV drug resistance is developing and the patient's antiretroviral medications become less effective in controlling HIV.

Prevention of OHL is heavily reliant on the early diagnosis and treatment of HIV, with current U.S. guidelines recommending initiation of ART at CD4 counts between 350 and 500 cells/mL, and even at CD4 counts above 500 cells/mL.

Smoking cessation is also highly recommended to prevent the appearance of OHL, as well as numerous other HIV-associated and non-HIV-associated morbidities.

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