There are three different types of papillae that cover the surface of tongue: fungiform, circumvallate, and filiform. The fungiform papillae are present on the tip, dorsal, and lateral part of the tongue and are involved in taste functions. Rarely, the papillae may be pigmented. The condition though innocuous becomes a matter of concern, especially in pediatric population. Even though pigmented fungiform papillae of the tongue (PFPT) is not so rare, it is seldom reported in the literature.
A 12-year-old male child presented with multiple red to dark-colored raised lesions on the tongue for the past 2 years [Figure 1]. The lesions were asymptomatic and nonprogressive. There was no other positive skin or medical history in the patient or his parents. Physical examination revealed the presence of multiple scattered to confluent, millimeter, hyperpigmented to erythematous papules over the dorsal aspect of the tongue. Dermoscopy (DermLite DL4; polarized mode with ×10) performed revealed the presence of a cobblestone pattern with multiple ovoid hyperpigmented projections having vessels originating from the base interspersed amid pinkish projections with linear dividing vessels at the base [Figure 2]. Based on the clinical and dermoscopic appearance, the patient was diagnosed as a case of mixed type I and II PFPT. The patient was counseled regarding the benign nature of the disease process, and no treatment was done.
PFPT is a benign condition which was initially described by Leonard in 1905. The usual age of presentation is the 2nd and 3rd decades; however, pediatric cases have also been reported in the literature. In a study by Chessa et al., the mean age of pediatric PFPT was 11 years which is similar to our case. PFPT does not have a clear-cut etiopathogenesis; however, activation of subepithelial melanophages is implicated in its pigmentation. Few authors have also suggested the role of abnormal fluctuation of sex hormones as the causative factor. The condition has been classified into three types by Holzwanger et al. Type I includes patients with a well-circumscribed hyperpigmented patch located either on the anterolateral aspect or tip of the tongue consisting of fungiform papillae where every single element presented with hyperpigmentation. Type II refers to hyperpigmentation involving 3–7 fungiform papillae scattered or slightly clustered on the dorsal lingual surface with an interspersion of normally pigmented fungiform and filiform papillae. Type III applies to patients with complete hyperpigmentation of every single fungiform papillae on the dorsum of the tongue. Our patient had overlap type I and II pattern. This type of overlap of patterns has also been described by Chessa et al. Dermoscopy is an important tool in identifying this entity. Overall dermoscopic appearance has been dubbed as cobblestone appearance of papillae. Each papilla is pigmented with slight of pigment toward the center and the presence of dichotomized vessels at the base giving it a rose petal appearance. The pigmentation is due to increased basal layer pigmentation. Our case had a similar cobblestone appearance; however, few papillae did not show pigmentation, while others did not have clear dichotomized vessels in the base. Since the condition is benign, invasive procedures are not required. If a biopsy is performed, histopathology usually reveals increased basal layer pigmentation and melanophages in the dermis without any exogenous pigment. PFPT does not have a strong association with any dermatological disease; few case reports have mentioned its association with lichen ruber planus, ichthyosis linearis circumflexa, and Laugier–Hunziker syndrome. Some authors have also reported this with systemic diseases such as iron deficiency, hemochromatosis, and scleroderma. Our case was not associated with any other skin or medical condition. Management usually consists of reassurance regarding the benign nature of this condition. There is no need to perform any invasive investigation or procedures, especially in children for PFPT. This report will help in adding to the existing repertoire of knowledge of clinical and dermoscopic features of PFPT so that we can use this to confirm our diagnosis and move away from invasive procedures.
Declaration of consent
The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s)/guardian(s) of the patient. In the form, the parent(s)/guardian(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child/children will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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1. Leonard TM. Ankylostomiasis or uncinariasis JAMA. 1905;45:588–94
2. Chessa MA, Patrizi A, Sechi A, Virdi A, Leuzzi M, Neri I. Pigmented fungiform lingual papillae: Dermoscopic and clinical features J Eur Acad Dermatol Venereol. 2018;32:935–9
3. Lin YT, Chou CL. Pigmented macule on the tongue of a 12-year-old girl J Am Acad Dermatol. 2013;69:e229–30
4. Holzwanger JM, Rudolph RI, Heaton CL. Pigmented fungiform papillae of the tongue: A common variant of oral pigmentation Int J Dermatol. 1974;13:403–8
5. Hsiao YH, Ko JH, Lu CF, Chen MJ. Dermoscopic findings in pigmented fungiform papillae of the tongue Eur J Dermatol. 2011;21:819–20
6. Mukamal LV, Ormiga P, Ramos-E-Silva M. Dermoscopy of the pigmented fungiform papillae of the tongue J Dermatol. 2012;39:397–9
7. Chamseddin B, Vandergriff T. Pigmented fungiform papillae of the tongue: A clinical and histologic description Dermatol Online J. 2019;25:11–2