Two-year history of tongue discomfort with spicy foods

Correct answer: B. Erythema migrans (benign migratory glossitis / geographic tongue)

• A. Median rhomboid glossitis is a single well-defined erythematous, papilla-free zone on the MIDLINE POSTERIOR dorsum, associated with candidal infection. It does not migrate.
• B. Correct. Erythema migrans presents as well-demarcated ERYTHEMATOUS PATCHES of filiform papillary atrophy surrounded by a raised white or yellow SERPIGINOUS border on the tongue dorsum. The pattern MIGRATES over days to weeks. Most patients are asymptomatic, but a substantial minority report burning or sensitivity specifically to SPICY, ACIDIC or hot foods — exactly as described.
• C. Oral lichen planus most often presents on the buccal mucosa bilaterally with Wickham's striae; the erosive form is painful but does not migrate.
• D. Burning mouth syndrome is burning pain with a CLINICALLY NORMAL mucosa — a diagnosis of exclusion. Here there are visible lesions.

Note: Erythema migrans is associated with FISSURED TONGUE and with psoriasis. It is entirely benign, and reassurance is a large part of management.

Correct answer: A. Topical triamcinolone

• A. Correct per the source key. Most cases need only reassurance and avoidance of trigger foods. When symptomatic, a topical corticosteroid such as TRIAMCINOLONE ACETONIDE in Orabase reduces the inflammation and burning. Topical anaesthetics and antihistamine rinses are also used.
• B. Surgical excision is never indicated for a benign migrating condition — the lesion will simply reappear elsewhere.
• C. There is no viral aetiology.
• D. Antifungals treat candidiasis; erythema migrans is not a fungal infection, although candidal superinfection can occur and confuse the picture.

Correct answer: C. Incisional biopsy

• A. Excisional biopsy is for small discrete lesions that can be removed in their entirety; a migrating patch on the tongue dorsum is not such a lesion.
• B. Immunofluorescence is used for the autoimmune vesiculobullous diseases, not for erythema migrans.
• C. Correct. Erythema migrans is normally a CLINICAL diagnosis and biopsy is rarely required. If the presentation is atypical or persistent, an INCISIONAL biopsy taken at the ACTIVE WHITE BORDER is the appropriate technique, showing a psoriasiform pattern with Munro microabscesses.
• D. Brush biopsy is a screening adjunct for suspicious flat white or red lesions and cannot provide architectural detail.