ConditionMouth & teeth
Oral Hairy Leukoplakia
Oral hairy leukoplakia (OHL) is a harmless white patch on the side of the tongue caused by the Epstein-Barr virus (EBV). The patch has vertical folds or ridges that can look "hairy" and, unlike thrush, it cannot be wiped off. It is not precancerous. It matters because it almost always signals a weakened immune system, most often from HIV, but also from organ transplant medicines, chemotherapy or long-term steroids. Anyone who develops it should be tested for HIV.
Also called: OHL, hairy leukoplakia, oral hairy leukoplakia of the tongue
At a glance
- What it is
- A benign white, ridged patch on the side of the tongue caused by Epstein-Barr virus.
- Who gets it
- People with weakened immunity, especially HIV. Rarely in healthy people.
- Key features
- Painless, does not rub off, usually on both sides of the tongue.
- Diagnosis
- Appearance, plus biopsy or EBV testing when unsure. HIV test for everyone.
- Treatment
- Often none. Treating HIV or the immune problem usually clears it.
When to get help
See a doctor within a day or two
- White patches with fever, night sweats, weight loss, or recurrent infections (possible HIV or other immune problem)
- A white or red patch with a lump, ulcer or bleeding
Book a routine appointment
- A white patch on the side of the tongue that cannot be wiped off
- Any white patch present more than 2 to 3 weeks
- A new white patch in someone on transplant medicines or chemotherapy
What causes oral hairy leukoplakia
Most adults carry the Epstein-Barr virus, the cause of glandular fever (infectious mononucleosis), in a dormant state for life. When the immune system is weakened, EBV can reactivate and multiply in the surface cells of the tongue. This causes the cells to thicken and fold, producing the characteristic patch.
Conditions that allow this include:
- HIV infection, especially with a low CD4 count. OHL was one of the early recognized signs of HIV and remains a marker of immune suppression.
- Organ or bone marrow transplant medicines
- Chemotherapy and blood cancers
- Long-term steroid use, including inhaled steroids in some cases
- Other immune-suppressing medicines
It occurs only rarely in people with normal immune function.
Symptoms and appearance
- white or grayish patches on the sides (lateral borders) of the tongue, often on both sides
- a corrugated surface with vertical folds, sometimes with hair-like projections
- patches do not rub off
- usually painless
- size can vary and change over time
- occasionally mild discomfort, altered taste, or concern about appearance
How it differs from other white patches
| Condition | Key differences |
|---|---|
| Oral hairy leukoplakia | Sides of tongue, vertical ridges, does not rub off, benign, linked to immune suppression |
| Oral thrush | Creamy white patches that wipe off, leaving red areas. Often anywhere in the mouth |
| Oral leukoplakia | Fixed white patch, often linked to tobacco, can be precancerous |
| Lichen planus | Lacy white lines, usually on the cheeks, sometimes sore |
| Frictional keratosis | From chewing or rubbing, fades when the cause stops |
Thrush and OHL often occur together in people with HIV.
Diagnosis
A doctor or dentist may suspect OHL from its appearance and location. To confirm:
- biopsy with tests for Epstein-Barr virus in the tissue, the definitive test
- an antifungal trial if thrush is also present, to see what remains
- HIV testing for anyone with OHL whose HIV status is unknown, along with a CD4 count and viral load if HIV is found
- other blood tests to look for immune problems if HIV is negative
Treatment
OHL itself is harmless, so treatment is often not needed. Options:
- Treat the underlying cause: starting antiretroviral therapy for HIV usually makes OHL disappear within weeks to months as the immune system recovers. Reducing immune-suppressing medicines, when possible, can also help.
- Antiviral medicines such as valacyclovir or acyclovir can clear the lesion, but it often returns after stopping.
- Topical treatments such as podophyllin resin or retinoids applied by a clinician, for cosmetic reasons.
- Treat coexisting thrush with antifungals.
Outlook
Oral hairy leukoplakia is benign and does not become cancer. It may come and go as immune function changes. Its main importance is as a sign: in people with HIV, it suggests the immune system is weakened and that treatment needs to start or be adjusted.
Frequently asked questions
What causes oral hairy leukoplakia?
It is caused by the Epstein-Barr virus becoming active in the tongue's surface cells. This happens mainly when the immune system is weakened, most commonly by HIV, but also by transplant medicines, chemotherapy or long-term steroids.
Is oral hairy leukoplakia a sign of HIV?
It often is. OHL is strongly associated with HIV and may be the first sign of infection. Anyone diagnosed with OHL should have an HIV test. It can also occur with other causes of immune suppression.
Is hairy leukoplakia cancerous?
No. Oral hairy leukoplakia is not precancerous and does not turn into cancer. This is different from ordinary oral leukoplakia, which can sometimes contain precancerous cells and needs monitoring.
How is oral hairy leukoplakia treated?
Treating the underlying immune problem, such as starting HIV treatment, usually clears it. Antiviral tablets or topical treatments can remove the patches, but they often come back if immunity remains low.
What is the difference between hairy leukoplakia and thrush?
Thrush is a yeast infection with creamy white patches that wipe off. Hairy leukoplakia is caused by a virus, has ridged white patches on the sides of the tongue, and cannot be wiped off. They can occur together.
Sources
This guide was written from current patient and clinical guidance, including:
- American Academy of Oral Medicine: Oral hairy leukoplakia
- CDC and NIH (Clinicalinfo.HIV.gov): Guidelines for prevention and treatment of opportunistic infections in adults with HIV
- MedlinePlus (US National Library of Medicine): Hairy leukoplakia
- DermNet: Oral hairy leukoplakia
- American Dental Association: Oral manifestations of HIV