Can oral candidiasis present as ulcers on the tongue?

Oral Candidiasis Does Not Typically Present as Primary Ulcers on the Tongue

Oral candidiasis classically presents as white plaques (pseudomembranous) or red patches (erythematous), not as primary ulcers. 1 However, ulceration can occur as a secondary complication when candidiasis extends to the esophagus or in rare severe cases.

Classic Presentations of Oral Candidiasis

The three recognized clinical patterns of oral candidiasis are:

• Pseudomembranous candidiasis: Creamy white, plaque-like lesions on the buccal mucosa, oropharynx, or tongue surface that can be scraped off 1
• Erythematous candidiasis: Red patches without white plaques, typically visible on the palate or diffusely on the tongue 1
• Angular cheilitis: Inflammation and cracking at the corners of the mouth 1

When Ulceration May Occur

Ulceration is not a primary feature of oral candidiasis but can develop in specific circumstances:

• Esophageal extension: When oral candidiasis progresses to oesophageal candidiasis (OEC), endoscopic examination may reveal whitish plaques that progress to superficial ulceration of the esophageal mucosa with central or surface whitish exudates 1
• Rare severe variant: One case report documented a patient with Non-Hodgkin's lymphoma who developed cheilocandidosis presenting as "an admixture of superficial erosions, ulcers and white plaques" on the vermilion borders of the lips 2

Critical Diagnostic Pitfall

If you see tongue ulcers without the characteristic white plaques or red patches of candidiasis, strongly consider alternative diagnoses:

• Recurrent aphthous stomatitis: Round or oval ulcers covered by gray-white fibrin layer with erythematous ring, associated with nutritional deficiencies (vitamin B12, folate, ferritin) 3
• Viral infections: HSV and CMV can cause ulcerative lesions in both immunocompromised and immunocompetent patients 4
• Other conditions: Lichen planus, pemphigus, or malignancy 3

Clinical Algorithm

When evaluating suspected oral candidiasis:

1. Look for characteristic features: White plaques that scrape off easily or red patches on tongue/palate 1
2. If ulcers are present without white plaques: This is atypical for oral candidiasis and warrants consideration of alternative diagnoses 1
3. Confirm diagnosis: Scrape lesions for microscopic examination showing hyphae/pseudohyphae, or initiate empiric antifungal therapy and assess response 1, 5
4. If ulcers persist despite antifungal treatment: Obtain biopsy to exclude other etiologies 4

Key Takeaway

Tongue ulcers as an isolated finding should prompt you to look beyond candidiasis. The presence of ulceration without the pathognomonic white plaques or erythematous patches makes oral candidiasis an unlikely primary diagnosis 1.