Smokers Keratosis

Non-pigmented epithelial naevi are rare in the oral cavity. They include white sponge naevus, oral epithelial naevi and naevi associated with naevus unius lateris.

White sponge naevus is an autosomal dominant inherited trait characterised by heaped up, sodden, irregular white plaques that can affect any part of the oral mucosa and may involve other mucosae including nasal, anal and vaginal (Cannon's syndrome). Microscopically, there is acanthosis with vacuolated cells in the stratum spinosum producing a basket weave appearance and irregular, shaggy parakeratosis. It is associated with a novel mutation in the keratin 4 gene [34].

Keratosis may be associated with both tobacco-smoking and -chewing. In smoker's keratosis the lesions appear to be a result of both thermal and chemical irritation. They rarely show significant dysplasia and appear to have a low pre-malignant potential. The affected mucosa may show diffuse whitening or more focal lesions and occasionally they are pigmented and have a slate-blue colour.

The epithelium can be hyperplastic or atrophic and is not dysplastic [136]. There is very variable parakeratosis or hyperorthokeratosis. Some cases show focal parakeratotic spikes ("chevrons"). Although such chevrons were thought to be most characteristic of smokeless tobacco-induced keratosis, only a minority of such lesions show this feature [40]. Pigmentary incontinence is common and may be florid in darkly pigmented individuals. Inflammatory infiltration is usually minimal.

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