What is the treatment for erythroplakia (erythroplasia) and leukoplakia (leukokeratosis) lesions?

Treatment of Erythroplakia and Leukoplakia

Primary Treatment Recommendation

For oral leukoplakia, photodynamic therapy with aminolevulinic acid (ALA-PDT) is the preferred treatment, particularly for extensive lesions or those in functionally sensitive areas, due to superior outcomes with minimal disfigurement compared to traditional surgical approaches. 1, 2 For erythroplakia, which carries significantly higher malignant transformation risk (often 50% or greater), immediate surgical excision with histopathologic examination is mandatory—observation is never appropriate. 3, 4

Risk Stratification (Critical First Step)

Non-homogeneous leukoplakia and all erythroplakia lesions carry 7-fold higher malignant transformation risk compared to homogeneous white plaques and require aggressive intervention regardless of initial biopsy findings. 5, 6

• Erythroplakia represents the most dangerous oral precursor lesion, with over 50% showing dysplasia, carcinoma in situ, or invasive carcinoma at diagnosis 4
• Non-homogeneous leukoplakia shows 15-20% malignant transformation rate versus only 3% for homogeneous lesions 5
• Lesions exceeding 200 mm² carry 5.4-fold increased malignant transformation risk 5

Treatment Algorithm for Leukoplakia

For Homogeneous Leukoplakia (Lower Risk)

ALA-PDT Protocol (Preferred): 1, 6

1. Pre-treatment verification:

   • Exclude absolute contraindications: porphyria history, coagulopathy, pregnancy, uncontrolled systemic disease, allergies to light/porphyrin/anesthesia 6
   • Verify vital signs: BP ≤140/90 mmHg, heart rate ≤100 bpm 6
   • Obtain baseline labs: CBC, glucose, coagulation studies, liver/kidney function 6

2. Treatment procedure:

   • Patient gargles with 0.1% chlorhexidine for 1 minute 6
   • Prepare 20% ALA aqueous solution immediately before use 1, 6
   • Apply photosensitizer-soaked swab extending 3-5 mm beyond lesion margins, cover with starch film and cling film 6
   • Incubate 2-3 hours 6
   • Apply local anesthesia (2% lidocaine or 4% primacaine) 1, 6
   • Laser parameters: 630 nm ± 5 nm wavelength, 100 mW/cm² power 1, 6
   • Irradiation: 3-minute exposure alternating with 3-minute rest periods until total dose reaches 100 J/cm² 1, 6
   • Repeat every 2-3 weeks based on healing response 1, 6

3. Expected outcomes:

   • Response rates: 50-100% 1, 6
   • Complete response: 16.49-88.89% 1, 6
   • Recurrence rates: 0-41% over 1-30 months 1, 6

For Non-Homogeneous Leukoplakia (Higher Risk)

Surgical excision is preferred over ALA-PDT due to the significantly elevated malignant transformation risk requiring complete histopathologic assessment. 5 However, ALA-PDT remains an option when surgical approaches risk functional impairment 1, 2

Treatment Algorithm for Erythroplakia

Complete surgical excision with adequate margins is mandatory for all erythroplakia lesions—no observation period is acceptable. 3, 4

• Erythroplakia shows dysplasia to invasive carcinoma in over 50% of cases at initial diagnosis 4
• Soft palate is affected in 77% of cases 4
• All excised tissue requires complete histopathologic examination to rule out invasive carcinoma 4

Post-Treatment Management (All Modalities)

Strict light avoidance for minimum 48 hours post-PDT is non-negotiable; for exposed sites like lips, extend throughout entire treatment course. 1, 6

• Prescribe 0.01% dexamethasone paste topically to reduce inflammation 1, 6
• Continue 0.1% chlorhexidine gargling solution 1, 6
• Instruct avoidance of irritating foods and beverages 1, 6
• Assess treatment response at 4 weeks after final treatment 1, 6

Alternative Surgical Options (When PDT Contraindicated or Inappropriate)

• CO2 laser ablation: Effective but causes more scarring than PDT 6
• Traditional surgical excision: Defects closed with mucosal flaps or free grafts 5
• Cryosurgery: Associated with postoperative pain, edema, and scarring 2, 6
• Electrocauterization: Higher risk of thermal damage 6

Long-Term Surveillance Requirements

All patients require lifelong follow-up regardless of treatment modality, as malignant transformation can occur years after initial intervention. 5, 7

• Mean time to malignant transformation: 6.6-7.5 years post-treatment 5
• Surgical excision does not eliminate malignant transformation risk (12% developed carcinoma post-excision versus 4% with observation alone) 5
• Tobacco cessation is essential, as 75-81% of oral cancers are attributable to tobacco and alcohol use 8, 5, 4
• Treat concurrent candidal infections 5

Critical Pitfalls to Avoid

• Never observe erythroplakia without immediate biopsy and excision—this is the most dangerous oral precursor lesion 3, 4
• Failing to enforce strict 48-hour light avoidance post-PDT compromises outcomes and increases complications 1, 6
• Do not assume benign hyperkeratosis on initial biopsy means low risk for non-homogeneous lesions—these require aggressive treatment regardless 6, 5
• Presence or absence of epithelial dysplasia on biopsy does not reliably predict malignant transformation risk 5
• Chemoprevention has no evidence supporting prevention of malignant transformation 1