25 year old woman presents with an 4 year evolving history of papules expanding to cover her inner cheeks, bilaterally. She complains of intermittent mild discomfort only. She is otherwise healthy, HIV-negative, and taking only OCP’s.
What is your diagnosis?
Heck's disease (also known as focal epithelial hyperplasia)
Heck’s disease is an uncommon condition characterized by white or flesh-colored papules that occur diffusely in the oral cavity. It is caused by the human papilloma virus types 13 and 32. In this particular case she had type 32. Type 13 is seen in younger children. The first case was described in 1965 in Native Americans. The majority of recent cases have been described in Native Central and South American populations.
The viral infection is very contagious and can be endemic among children in close areas- sometimes as many as 30% of the children in a community can be affected. Adults seem to have minimal evidence of residual oral lesions and so the lesions are presumed to eventually disappear on their own over time.
Risk factors for this condition include poor hygiene, low socioeconomic status, immunosuppression and living in close proximity to others. Extensive lesions have been reported in HIV-positive patients.
It is most commonly seen in children and young adults. Treatment is only symptomatic and the lesions eventually disappear.
Because this patient was mildly symptomatic, I had her try imiquimod5% cream daily to a small area on her inner cheek. 30 days in to treatment she reports noticeable improvement and wishes to continue.