Oral verrucous hyperplasia due to repetitive chewing on lips.

Fifty-year-old male smoker presented with a slow-growing raised lesion on the mucosal surface of his upper lip (Fig. 1). He underwent an excisional biopsy and pathology confirmed verrucous hyperplasia without evidence of malignancy as shown in Fig. 2. Patient made an uneventful recovery.

Fig. 1

A 5 mm raised irregular lesion along the mucosal surface of upper lip to the right of midline.

Fig. 2

Broad, short, and blunt verrucous projections with parakeratinized epithelium that does not invade the lamina propria.

The most common site of presentation involves the buccal mucosa (48%) followed by the tongue (20%), palate (18%), gingiva (7%), and labial mucosa (7%) (1). Causative factors include smoking cigarettes, smokeless tobacco, chewing habits, poor oral hygiene, and alcohol consumption. Clinically, oral verrucous hyperplasia (OVH) resembles verrucous carcinoma and these can generally only be distinguished from each other by histopathology. Although no consensus guidelines exist, the following criteria is proposed by Kallarakkal et al. for the diagnosis of verrucous hyperplasia (2):

Long and narrow heavily keratinized verrucous processes or broad and flat verrucous processes that are less keratinized.

Absence of invasion of the hyperplastic epithelium into the lamina propria as compared with the adjacent normal mucosal epithelium.

Presence of cytological features of dysplasia.

The absence of invasion into the lamina propria is the main feature distinguishing verrucous hyperplasia from verrucous carcinoma, and the presence of dysplasia is common but not always (3). The two entities should be managed similarly because of the significant overlap in their clinicopathologic features. Treatment involves total surgical excision. Recurrence and transformation of OVH to either verrucous carcinoma or squamous cell carcinoma have been reported after surgical intervention (4). Wide surgical excision with adequate mucosal and soft tissue margin is necessary to avoid recurrence (5).

This case highlights the importance of considering verrucous carcinoma in the differential diagnosis of OVH and the importance of surgical treatment even in the absence of dysplasia because of the premalignant nature of these lesions.