Dermoscopy of Focal Epithelial Hyperplasia

Sir,

Focal epithelial hyperplasia (FEH), also known as Heck's disease, is a rare condition associated with infection of subtypes of human papilloma virus (HPV). The two main subtypes of HPV associated with Heck's disease are HPV 13 and 32. The most common presentation of FEH is in the form of asymptomatic papules over the oral mucosa. FEH usually presents during childhood or adolescence and tends to have a benign course.[1,2]

A 21-year-old female patient presented to us with a history of asymptomatic, raised skin eruptions over the lower lip. The lesions were first noticed by the patient around 2 years ago and gradually increased in size and number. The lesions were not interfering mastication, but the patient was concerned regarding the cosmetic appearance. The patient did not have any other significant skin problem elsewhere on her body. The patient was otherwise healthy with no previous history of any significant skin or systemic diseases. There was also no family history of such condition.

On examination, soft papules were seen over the mucosal aspect of the lower lip. The lesions were having the color of the normal buccal mucosa but with whitish striation on the surface [Figure 1]. The upper lip mucosa, buccal mucosa, and tongue were unaffected. Histopathology showed acanthosis, focal parakeratosis with broad rete pegs along with typical koilocytic changes, and nuclear features resembling “mitosoid” bodies [Figure 2]. Based on the clinical presentation and the histopathology, a diagnosis of FEH was made. Polymerase chain reaction (PCR) for HPV was not done in this patient.

Figure 1.

Soft, sessile papules and plaques over the lower lip mucosa

Figure 2.

Histopathology showing acanthosis, focal parakeratosis with broad rete pegs along with typical koilocytic changes, and nuclear features resembling “mitosoid” bodies (H and E, ×200)

Dermoscopy (polarized, 10×, Dermlite Foto II Pro) showed relatively well-defined lobules separated by white septations. Within the lobules, prominent polymorphic vascular patterns – linear, branching vessels, dendritic vessels, and hairpin vessels – were seen over an orange-yellow colored background [Figure 3]. The patient was started on cryotherapy with liquid nitrogen and was under follow up.

Figure 3.

Dermoscopy, polarized, 10x showing relatively well-defined lobules (black circle) separated by white septations (blue arrow). Within the lobules, prominent polymorphic vascular patterns – linear, branching vessels, dendritic vessels and hairpin vessels (red arrow) – were seen over an orange-yellow colored background (black arrow)

FEH, otherwise known as Heck's disease, is a rare condition associated with HPV 13 and 31. The typical presentation is in the form of asymptomatic papules in the oral mucosa, most commonly in children and adolescents. The disease tends to have a benign, self-remitting course. Treatment is required for cosmetic reasons and in cases where the lesions interfere with mastication. Treatment options include cryotherapy, topical imiquimod, topical retinoids, surgical excision, ablative lasers, and intralesional interferons.[2] Although PCR is the gold standard to demonstrate HPV 13 and 32 in case of FEH, it may not be positive in all cases.[3]

To the best of our knowledge, the dermoscopy of FEH has not been described before, but the patterns seen seem to be similar to those described in the case of mucosal warts/condyloma, which are also characterized by prominent polymorphic vascular patterns.[4] The lobules and septation could possibly represent the acanthosis and parakeratosis, and the multiple vessels and vascular distension visible on histopathology are reflected in the vascular patterns seen on dermoscopy.

To conclude, FEH is characterized by a dermoscopy pattern showing prominent polymorphic vessels, like in mucosal warts. The vascular patterns include linear, branching vessels, dendritic, and hairpin vessels. The vessels are seen over an orange-yellow background in lobules separated by whitish septations.

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Conflicts of interest

There are no conflicts of interest.