Peer Reviewed

Photo Essay

An Atlas of Lingual Lesions, Part 2

  • Alexander K. C. Leung, MD
    Clinical Professor of Pediatrics, University of Calgary; Pediatric Consultant, Alberta Children’s Hospital, Calgary, Alberta, Canada

    Benjamin Barankin, MD
    Dermatologist, Medical Director, and Founder, Toronto Dermatology Centre, Toronto, Ontario, Canada

    Kin Fon Leong, MD
    Pediatric Dermatologist, Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia

    Helen Tam-Tham, PhD
    Medical Student, University of Calgary, Calgary, Alberta, Canada

    Leung AKC, Barankin B, Leong KF, Tam-Tham H. An atlas of lingual lesions, part 2. Consultant. 2019;59(6):180-183.

    EDITOR’S NOTE: This article is part 2 of a 5-part series of Photo Essays describing and differentiating conditions affecting the tongue and related structures in the oral cavity. Part 1 was published in the May 2019 issue (access it at Parts 3 through 5 will be published in upcoming issues of Consultant.


    Oral Candidiasis

    Oral candidiasis is most commonly caused by Candida albicans and occasionally by Candida glabrata, Candida guilliermondii, Candida tropicalis, Candida pseudotropicalis, Candida lusitaniae, Candida krusei, Candida parapsilosis, and Candida dubliniensis.1,2 It is the most common fungal infection in the oral cavity of infants and among predisposed individuals at any age.1 

    In the pediatric age group, oral candidiasis affects 2% to 5% of otherwise healthy newborn infants.1 Premature and very-low-birth-weight infants are at the highest risk.1 The sex ratio is approximately equal.1 

    Predisposing factors include the use of broad-spectrum antibiotics, the use of inhaled or systemic corticosteroids, diabetes mellitus, xerostomia, chemotherapy, radiation therapy to the head and neck area, cellular immunodeficiency states such as HIV, and older adults who wear dentures.3-5

    The classic (most common) presentation of oral candidiasis is pseudomembranous candidiasis (commonly known as oral thrush), which is characterized by white, curd-like, discrete coating or plaques on the tongue, buccal mucosa, soft palate, hard palate, and oral pharynx (Figures 1 and 2).6 The adherent pseudomembrane is composed of desquamated epithelial cells, keratin, leukocytes, necrotic tissue, and food particles. Removal of the plaques by wiping with gauze may reveal raw, erythematous, and sometimes bleeding mucosa underneath.6 Oropharyngeal candidiasis, if severe, can impair speech, feeding, and quality of life.1 Occasionally, the infection can spread to the esophagus, resulting in esophageal candidiasis.1


    candidiasis 1
    Figure 1

    Candidiasis 2
    Figure 2

    Erythematous oral candidiasis, also known as atrophic candidiasis, is characterized by smooth erythematous patches occurring most often on the palate, gum, and dorsum of the tongue, with no evidence of pseudomembranous overgrowth.2 The color intensity may vary from fiery red to a hardly discernable pink spot.1 Characteristically, chronic atrophic candidiasis, a subset of erythematous oral candidiasis, occurs in patients wearing dentures, and the lesion is typically limited to the gingival mucosa in contact with the denture.

    Oral candidiasis is usually asymptomatic.4,5 Some children may experience fussiness, decreased feeding, and/or refusal to feed. Older children and adults may experience a metallic, bitter, or sour taste, a burning sensation in the mouth, dysphagia, and halitosis.4,5 There is a tendency for easy bleeding of the affected areas.5

    The diagnosis is often clinical, especially if the lesion has a classical presentation. If necessary, the diagnosis can be confirmed by potassium hydroxide wet-mount examination of swabs taken from the affected area or by culture of the fungus.

    For treatment, oral candidiasis usually responds well to oral nystatin, fluconazole, itraconazole, or clotrimazole.1 The duration of treatment usually is 2 weeks, but the medication should be continued 2 to 3 days beyond resolution of the lesion.


    1. Leung AKC. Oral candidiasis. In: Leung AKC, ed. Common Problems in Ambulatory Pediatrics: Specific Clinical Problems. Vol 2. New York, NY: Nova Science Publishers; 2011:143-147.
    2. Hellstein JW, Marek CL. Candidiasis: red and white manifestations in the oral cavity. Head Neck Pathol. 2019;13(1):25-32.
    3. Dekhuijzen PNR, Batsiou M, Bjermer L, et al. Incidence of oral thrush in patients with COPD prescribed inhaled corticosteroids: effect of drug, dose, and device. Respir Med. 2016;120:54-63.
    4. Meira HC, De Oliveira BM, Pereira IF, Naves MD, Mesquita RA, Santos VR. Oral candidiasis: a retrospective study of 276 Brazilian patients. J Oral Maxillofac Pathol. 2017;21(3):351-355.
    5. Mushi MF, Bader O, Taverne-Ghadwal L, Bii C, Groß U, Mshana SE. Oral candidiasis among African human immunodeficiency virus-infected individuals: 10 years of systematic review and meta-analysis from sub-Saharan Africa. J Oral Microbiol. 2017;9(1):1317579.
    6. Millsop JW, Fazel N. Oral candidiasis. Clin Dermatol. 2016;34(4):487-494.

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