HIV and Oral Hairy Leukoplakia

Oral lesions may foreshadow disease progression

Hairy leukoplakia (also known as oral hairy leukoplakia, or OHL) is a commonly seen an oral lesion in immune-compromised people, manifesting 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.

man wearing face mask waiting for doctor
 Trevor Williams / Getty Images

Causes and Symptoms

OHL is caused by the Epstein Barr virus (EBV), a virus of the herpes family that affects almost 95 percent of the population. While most people have an immune system able to control the virus, the diminished immune function in people with HIV provides OHL the opportunity to thrive. As such, it is considered an HIV-associated opportunistic infection.

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 opportunistic infections. 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 percent progressed from HIV to AIDS within the two years. Today, with the earlier treatment, the incidence of OHL has dropped significantly.

In terms of risk factors, smoking in association with a low CD4 count translates to a nearly two-fold increase in the risk of OHL.


OHL lesions vary in size. They 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 percent of visual exams 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.

Treatment and Prevention

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

Prevention of OHL is heavily reliant on the early diagnosis and treatment of HIV with current U.S. guidelines recommending treatment upon diagnosis.

Smoking cessation is also recommended to prevent the development of OHL as well as numerous other HIV-associated and non-HIV-associated illnesses.

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By James Myhre & Dennis Sifris, MD
Dennis Sifris, MD, is an HIV specialist and Medical Director of LifeSense Disease Management. James Myhre is an American journalist and HIV educator.