Palatal Lesion with White Exudate and Tenderness: Diagnosis and Management
The most likely diagnosis is oropharyngeal candidiasis, which should be treated with topical or systemic antifungal therapy after confirming the diagnosis by scraping the lesion to verify the white exudate can be removed and examining it microscopically for yeast forms. 1
Clinical Diagnosis
Oropharyngeal candidiasis presents as painless, creamy white, plaque-like lesions on the buccal, oropharyngeal mucosa, or palate that can be easily scraped off with a tongue depressor. 1 The key distinguishing feature is that these white plaques are removable, unlike other white lesions such as oral hairy leukoplakia. 1
Critical Diagnostic Steps:
- Attempt to scrape the white exudate with a tongue depressor or similar instrument - if it removes easily, this strongly supports candidiasis 1
- Obtain a KOH preparation of the scraped material to demonstrate yeast forms microscopically for laboratory confirmation if needed 1
- Culture the material to identify the specific Candida species present, particularly if treatment failure occurs 1
Risk Factors to Assess
Evaluate for immunosuppression, as oropharyngeal candidiasis typically occurs in patients with CD4+ counts <200 cells/µL or other immunocompromised states. 1 Key risk factors include:
- HIV infection with advanced immunosuppression 1
- Recent antibiotic use 1
- Immunosuppressive medications 1
- Diabetes or other conditions causing compromised immunity 1
Alternative Diagnoses to Consider
While candidiasis is most likely, any oral abnormality lasting more than 2 weeks should be reevaluated and considered for biopsy to exclude malignancy or other serious conditions. 1
Other Differential Diagnoses:
- Recurrent aphthous ulceration - presents with well-demarcated ulcers with yellow/white base and erythematous border 2
- Traumatic ulceration - related to sharp food, dental appliances, or iatrogenic causes 2
- Herpes simplex virus - typically presents with shallow ulcers 1
- Squamous cell carcinoma - particularly in patients >40 years with tobacco/alcohol use; presents as persistent ulcer or mass 1
- Lichen planus - may show pale, edematous mucosa with peeling/sloughing and thick white exudates 1
Treatment Approach
For confirmed oropharyngeal candidiasis, initiate antifungal therapy with topical agents for mild cases or systemic azoles for moderate-to-severe disease. 1
Treatment Options:
- Topical therapy: Clotrimazole troches or nystatin suspension for initial episodes 1
- Systemic therapy: Fluconazole for more extensive disease or when topical therapy fails 1
- Consider fluconazole resistance if there is history of repeated or long-term azole exposure, which may necessitate alternative agents 1
Critical Red Flags Requiring Urgent Action
Refer to otolaryngology or oral surgery if:
- The lesion persists beyond 2 weeks despite appropriate antifungal treatment - biopsy is mandatory to exclude dysplasia or malignancy 1, 2
- Associated symptoms include dysphagia, odynophagia, weight loss, or hemoptysis - these suggest possible esophageal involvement or malignancy 1
- The patient has risk factors for malignancy (age >40, tobacco/alcohol use, HPV exposure) and the lesion appears as a non-healing ulcer or mass 1
- Tonsil asymmetry or fixed mass is present on examination 1
Common Pitfalls to Avoid
- Do not assume all white palatal lesions are candidiasis - hyperkeratosis from smokeless tobacco use appears as white patches that do not rub off and requires biopsy if persistent after tobacco cessation 3
- Do not delay biopsy for persistent lesions - squamous cell carcinoma accounts for 95% of oral cancers and is often asymptomatic until late stage 3
- Do not overlook systemic conditions that may present with oral ulceration, including autoimmune diseases, nutritional deficiencies, or blood disorders 2, 4
- In tender lesions, do not miss medication-induced ulceration (e.g., doxycycline) which typically presents as 1-2 well-marked ulcerations 1