Erythroplakia: Symptoms, Types, Causes and Treatment

Erythroplakia is a rare but clinically significant lesion of the oral mucosa, distinguished by its striking red appearance and its high risk of malignant transformation. While its occurrence is uncommon, erythroplakia demands immediate attention due to its strong association with severe dysplasia and oral squamous cell carcinoma. In this comprehensive article, we explore the key aspects of erythroplakia, including its symptoms, the main types, underlying causes, and the best approaches for diagnosis and treatment.

Symptoms of Erythroplakia

Recognizing the symptoms of erythroplakia early is vital, as these lesions often represent precancerous changes in the oral cavity. The symptoms can be subtle, making regular oral examinations and awareness crucial for early detection.

Symptom	Description	Risk/Implication	Source
Red Patch	Well-defined, velvety, homogenously red area	High malignancy potential	5 8
Asymptomatic	Often painless or without discomfort	May delay diagnosis	5 4
Burning Sensation	Occasional mild burning or sensitivity	Early indicator in some cases	5
Induration	Firmness or thickening of lesion	Suggestive of invasive disease	5

Table 1: Key Symptoms

Understanding the Clinical Presentation

Erythroplakia usually appears as a well-demarcated, velvety red patch in the oral cavity, most commonly on high-risk sites such as the ventral surface of the tongue, floor of the mouth, or the soft palate. Unlike other oral lesions, erythroplakia is typically homogenously red, lacking the white patches that characterize leukoplakia or erythroleukoplakia 5.

Asymptomatic Nature

One of the most challenging aspects of erythroplakia is its asymptomatic presentation. Most patients do not report pain or discomfort, which can result in delayed detection until the lesion becomes more advanced or is incidentally found during a dental or medical examination 5 4.

Occasional Symptoms

A subset of patients may notice a burning sensation or mild sensitivity at the lesion site, particularly during eating or drinking spicy foods. Some lesions may also develop raised, indurated borders or become slightly tender as they progress toward dysplasia or carcinoma 5.

Importance of Early Identification

Given the high risk of malignant transformation (with up to 85% of cases showing squamous cell carcinoma on histology), any persistent, unexplained red patch in the oral cavity—especially in individuals with risk factors—should prompt immediate evaluation and biopsy 5 8. Regular oral health check-ups are essential for early detection, especially in high-risk populations.

Types of Erythroplakia

Erythroplakia is not a uniform clinical entity. Understanding its types and variants is critical for risk assessment and management.

Type/Variant	Key Features	Malignancy Risk	Source
Homogenous Erythroplakia	Uniformly red, smooth, velvety patch	High	5 8
Erythroleukoplakia	Mixed red and white areas (red predominates)	Very high (MT: 100%)	1
Proliferative Variants	Large, multifocal, or contiguous lesions	Increased recurrence	1 6
Carcinoma in situ	Histologically confirmed severe dysplasia	Extremely high	3 5

Table 2: Erythroplakia Types and Variants

Homogenous Erythroplakia

This is the classic form: a single, flat or slightly depressed, velvety red lesion with well-defined margins. The surface texture is typically smooth, and the color is uniformly red. Histologically, these lesions often harbor severe dysplasia or carcinoma in situ 5 8.

Erythroleukoplakia

Erythroleukoplakia presents as mixed red and white lesions, with the red component predominating. This variant is particularly alarming because it carries an even higher risk of malignant transformation, with studies showing a 100% transformation rate in some subsets 1. It is sometimes also called "speckled leukoplakia."

Proliferative Variants

Some lesions are multifocal or large and contiguous, spreading across multiple sites in the oral cavity. These are sometimes grouped under proliferative erythroleukoplakia or proliferative leukoplakia. These variants are associated with greater risk of recurrence after excision and a higher likelihood of malignant progression 1 6.

Carcinoma In Situ

When erythroplakia is biopsied, it may reveal carcinoma in situ—the final step before invasive cancer. These cases require prompt and aggressive management due to their extremely high risk profile 3 5.

Causes of Erythroplakia

The exact cause of erythroplakia remains unclear, but multiple etiological factors and pathogenic mechanisms have been identified, many of which overlap with those of oral cancer.

Cause/Factor	Description/Impact	Relative Risk	Source
Tobacco Use	Chewing/smoking; major risk factor	Strong (OR: 19.8)	2 4 8
Alcohol Consumption	Excessive/regular intake	Moderate (OR: 3.0)	2 5 8
Nutritional Deficiency	Low fruit/vegetable intake	Amplifies risk	2
Genetic Alterations	p53 mutations, early DNA changes	High	3

Table 3: Key Causes and Risk Factors

Tobacco Use

Chewing and smoking tobacco are the most potent risk factors for erythroplakia, with a case-control study reporting an adjusted odds ratio of 19.8 for individuals who had ever chewed tobacco 2. The risk is particularly high in populations where tobacco chewing is prevalent, such as in India and parts of Southeast Asia 2 4 8.

Alcohol Consumption

Regular or excessive alcohol intake further increases the risk, both independently and synergistically with tobacco use. Alcohol is thought to act as a solvent, enhancing the penetration of carcinogens in tobacco into the oral mucosa. The odds ratio for ever-alcohol drinkers was found to be 3.0 2 5 8.

Nutritional Deficiency

A low intake of vegetables and fruits can amplify the risk, especially when combined with tobacco or alcohol use. The presence of certain micronutrient deficiencies may impair mucosal repair and increase susceptibility to carcinogens 2.

Genetic and Molecular Changes

Up to 46% of erythroplakia lesions harbor mutations in the p53 tumor-suppressor gene, a rate significantly higher than in leukoplakia. These mutations are present at all stages of dysplasia, suggesting a direct link between p53 dysfunction and the high malignant potential of erythroplakia 3. This supports the concept that genetic alterations occur early in the lesion’s development, predisposing it to malignant transformation.

Other Factors

Additional contributors may include betel quid chewing, chronic irritation, and family history of cancer 1 4 8. However, the majority of cases are linked to modifiable lifestyle factors.

Treatment of Erythroplakia

Given its high risk for cancer, erythroplakia requires prompt, definitive management. The treatment approach centers on complete excision, vigilant follow-up, and risk factor modification.

Treatment	Description/Approach	Outcomes/Considerations	Source
Surgical Excision	Complete removal with adequate margins	Low morbidity, recurrence risk	6 7 8
Laser Ablation	CO2 laser excision, especially for small lesions	Effective, low morbidity	6 8
Imaging Guidance	Narrow band imaging to define margins	Improved margin clearance	7
Risk Modification	Cessation of tobacco/alcohol, nutrition	Reduces recurrence, progression	2 8
Long-term Follow-up	Regular monitoring for recurrence/cancer	Essential due to high risk	6 8

Table 4: Treatment Approaches

Surgical Excision

The gold standard treatment for erythroplakia is complete surgical excision of the lesion with adequate margins. This allows for both therapeutic removal and definitive histopathological assessment 6 7 8. Excision is especially urgent if the lesion harbors severe dysplasia or carcinoma in situ.

Laser Ablation

CO₂ laser excision is increasingly used due to its precision and ability to minimize damage to surrounding tissues. In a large cohort, laser excision yielded low postoperative morbidity and no malignant transformation when lesions were still confined to dysplasia 6.

Imaging Guidance

One of the challenges in treating erythroplakia is accurately delineating the lesion’s margins. Narrow band imaging (NBI) is a novel endoscopic technique that enhances visualization of abnormal vasculature, helping surgeons achieve clearer resection margins and potentially reducing recurrence 7.

Risk Factor Modification

Addressing underlying risk factors is essential. Patients are strongly advised to stop tobacco use and alcohol consumption and improve their diet, particularly by increasing fruit and vegetable intake 2 8. These lifestyle changes not only support healing but also reduce the risk of recurrence and malignant transformation.

Long-term Follow-up

Due to the high recurrence rate (up to 16.7% in some excised cases) and ongoing risk of malignant transformation, long-term, close follow-up is mandatory. Surveillance should include regular clinical examinations and, if necessary, repeat biopsies of any suspicious areas 6 8. Larger lesions (area >80 mm²) are associated with a significantly higher risk of recurrence 6.

Conclusion

Erythroplakia is a rare yet highly significant oral lesion that carries an exceptional risk for progression to oral cancer. Understanding its symptoms, types, causes, and evidence-based management is crucial for clinicians and patients alike. Early detection, targeted treatment, and ongoing surveillance offer the best chance for favorable outcomes.

Key Takeaways:

• Symptoms: Erythroplakia often presents as a painless, well-defined, velvety red patch, most commonly on high-risk oral sites 5.
• Types: Includes homogenous erythroplakia, erythroleukoplakia (mixed red and white), proliferative forms, and carcinoma in situ; erythroleukoplakia and proliferative types carry the highest malignancy risk 1 5.
• Causes: Strongly linked to tobacco use, alcohol consumption, poor nutrition, and early genetic mutations (notably p53); modifiable lifestyle factors play a major role 2 3 8.
• Treatment: Complete excision—often with laser or imaging guidance—is the standard, with risk modification and long-term follow-up essential to minimize recurrence and malignant transformation 6 7 8.

By remaining vigilant and proactive in prevention, diagnosis, and management, the significant threat posed by erythroplakia can be effectively addressed.