Red Patches on a 10-Year-Old’s Tongue

What's Your Diagnosis?

A 10-year-old boy was noted to have erythematous patches on his tongue 9 months ago. The patches changed shape, size, and location over time. The child was asymptomatic and had normal appetite.

PHYSICAL EXAMINATION

Physical examination revealed multifocal, irregular patches on the dorsum of the tongue. The rest of the examination was unremarkable.

What’s Your Diagnosis?

(Answer and discussion on next page)

ANSWER: Geographic Tongue

Geographic tongue is an inflammatory disorder of the mucosa of the tongue.¹ The condition is characterized by a maplike distribution of irregular bright red patches on the dorsum of the tongue. The lesion usually is surrounded by a slightly elevated, white or yellowish white, circinate, linear border.² Synonyms include benign migratory glossitis, erythema migrans, annulus migrans, and wandering rash of the tongue.

EPIDEMIOLOGY

Although the prevalence of geographic tongue is highly variable, most studies report a range between 1% and 2.5%.^1-5 The condition occurs more commonly in children, and its frequency diminishes with age.^1,3 While some studies have shown a female to male ratio of 1.5:1 to 2:1,^1,6 other studies have reported similar rates by sex.⁷ The prevalence of geographic tongue is higher in the white and African American populations compared with the Mexican American population.^2,8 There is an inverse association with cigarette smoking.⁹

EtIOLOGY

The exact etiology is not known. Most cases are idiopathic.¹ There is a genetic predisposition to the condition; polymorphism in the interleukin-1β (IL1B) gene at nucleotide position +3954 is associated with an increased risk.¹⁰ Associations with human leukocyte antigens HLA-B15, HLA-DR5, HLA-DRw6, and HLA-Cw6 also have been reported.^11,12 Several conditions associated with geographic tongue have been described, including atopy, psoriasis, fissured tongue, type 1 diabetes mellitus, seborrheic dermatitis, hormonal disturbances, pregnancy, the use of oral contraceptives, emotional stress, Crohn disease, Down syndrome, and Reiter syndrome.^1,5,8,13

Clinical Manifestations

Clinically, geographic tongue presents on the dorsum of the tongue as multifocal, circinate or irregular, smooth, erythematous patches that represent atrophy or loss of filiform papillae and a thinning of the epithelium.^1,14,15 Often a serpiginous, slightly raised, white or yellowish white border is present.^1,2 The white border is composed of regenerating filiform papillae and a mixture of keratin and neutrophils.¹² These lesions tend to change in shape, size, and location over time, giving the tongue a variegated appearance. They heal spontaneously but reappear at another site, thereby accounting for the description of “migratory.” The majority of patients with geographic tongue are asymptomatic, and the lesion often is discovered during routine oral examination.^1,14,15 Rarely, affected individuals experience discomfort, pain, stinging, or a burning sensation when eating spicy or acidic foods.^13,14

Typically, the lesions primarily affect the dorsal surface of the tongue. Similar lesions have been described in other areas of the oral mucosa, and these have been referred to as geographic stomatitis.^2,3 Rarely, lesions may involve the ventral surface of the tongue.⁸

Diagnosis

The diagnosis of geographic tongue is mainly clinical based on the history of a migrating pattern and the characteristic clinical appearance. No laboratory test is necessary.

The differential diagnosis includes oral candidiasis, local trauma, recurrent aphthous stomatitis, herpes simplex, drug reaction, leukoplakia, lichen planus, and psoriasis, each of which has a unique clinical presentation.¹

Prognosis AND MANAGEMENT

Geographic tongue is a benign and self-limiting condition. Typically, the lesion resolves spontaneously without sequelae but tends to recur in other areas of the tongue. No treatment is required apart from reassurance. n

REFERENCES:

1. Assimakopoulos D, Patrikakos G, Fotika C, Elisaf M. Benign migratory glossitis or geographic tongue: an enigmatic oral lesion. Am J Med. 2002;113(9):751-755.

2. Shulman JD, Carpenter WM. Prevalence and risk factors associated with geographic tongue among US adults. Oral Dis. 2006;12(4):381-386.

3. Cambiaghi S, Colonna C, Cavalli R. Geographic tongue in two children with nonpustular psoriasis. Pediatr Dermatol. 2005;22(1):83-85.

4. Koay CL, Lim JA, Siar CH. The prevalence of tongue lesions in Malaysian dental outpatients from the Klang Valley area. Oral Dis. 2011;17(2):
210-216.

5. Miloğlu Ö, Göregen M, Akgül M, Acemoğlu H. The prevalence and risk factors associated with benign migratory glossitis lesions in 7619 Turkish dental outpatients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;
107(2):e29-e33.

6. Jainkittivong A, Langlais RP. Geographic tongue: clinical characteristics of 188 cases. J Contemp Dent Pract. 2005;6(1):123-135.

7. Avcu N, Kanli A. The prevalence of tongue lesions in 5150 Turkish dental outpatients. Oral Dis. 2003;9(4):188-195.

8. Zadik Y, Drucker S, Pallmon S. Migratory stomatitis (ectopic geographic tongue) on the floor of the mouth. J Am Acad Dermatol. 2011;65(2):
459-460.

9. Reamy BV, Derby R, Bunt CW. Common tongue conditions in primary care. Am Fam Physician. 2010;81(5):627-634.

10. Guimarães ALS, Correia-Silva JdF, Diniz MG, Xavier GM, Horta MCR, Gomez RS. Investigation of functional gene polymorphisms: IL-1B, IL-6 and TNFA in benign migratory glossitis in Brazilian individuals. J Oral Pathol Med. 2007;36(9):533-537.

11. Fenerli A, Papanicolaou S, Papanicolaou M, Laskaris G. Histocompatibility antigens and geographic tongue. Oral Surg Oral Med Oral Pathol. 1993;76(4):476-479.

12. Goregen M, Melikoglu M, Miloglu O, Erdem T. Predisposition of allergy in patients with benign migratory glossitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;110(4):470-474.

13. Menni S, Boccardi D, Crosti C. Painful geographic tongue (benign migratory glossitis) in a child. J Eur Acad Dermatol Venereol. 2004;18(6):736-738.

14. Anderson KM, Sedghizadeh P, Allen CM, Camisa C. Oral disease. In: Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. Philadelphia, PA: Mosby; 2003:1079-1080.

15. Leung AKC. Atopic dermatitis. In: Leung AKC, ed. Common Problems in Ambulatory Pediatrics: Specific Clinical Problems. Vol 2. New York, NY: Nova Science Publishers; 2011:303-314.