Pigmented Fungiform Papillae of the Tongue: Clinical and Dermoscopic Features

Dear Editor, Pigmented fungiform papillae of the tongue (PFPT) or pigmented fungiform lingual papillae, also known as papillary tip melanosis, is a benign condition characterized by hyperpigmentation of the fungiform papillae, first described by Leonard in 1905.1 PFPT is relatively uncommon and may lead to unnecessary concern. Dermoscopy is helpful in the diagnosis of pigmented lesions of the tongue, including PFPT.2 We report the dermoscopic features of PFPT, emphasizing on its role in differentiating it from other pigmented lesions of the tongue. A 30-year-old woman presented with asymptomatic black spots on her tongue, noticed over the past several years. The patient reported no associated symptoms, such as pain, burning, or changes in taste. Her medical history was unremarkable, with no history of tobacco use or significant systemic illness. On clinical examination, multiple discrete, round, black-pigmented fungiform papillae interspersed with non-pigmented fungiform papillae were observed on the anterior thirds of the dorsal tongue, predominantly over the tip Figure 1. Dermoscopy revealed a cobblestone-like arrangement of pigmented papillae. Each pigmented papilla exhibited projections with pigmented tips and branching vessels originating from the base, forming a characteristic ‘rose petal’ pattern. In contrast, the non-pigmented papillae showed only branching vessels from the base without any pigmentation Figure 2. Interspersed filiform papillae were also observed. Based on the clinical and dermoscopic findings, a diagnosis of PFPT was made. The patient was reassured about the benign nature of the condition, and no further intervention was deemed necessary.Figure 1: Multiple discrete, round, black-pigmented fungiform papillae interspersed with non-pigmented fungiform papillae on the anterior thirds of the dorsal tongue, predominantly involving the tipFigure 2: Polarized dermoscopy (Heine DELTAone; 20x) showing a cobblestone-like arrangement of pigmented papillae with each pigmented papilla exhibiting projections with pigmented tips and branching vessels originating from the base, forming a characteristic ‘rose petal’ pattern (green arrow). In contrast, the non-pigmented papillae are showing branching vessels from the base without any pigmentation (blue arrow). Interspersed filiform papillae are also noted (yellow arrow)PFPT is more commonly observed in individuals with darker skin types, particularly those of African or Asian descent. It often presents in adulthood, with a slight female predominance.2 The exact aetiology of PFPT remains unclear. It is hypothesized to result from increased melanin deposition within the fungiform papillae.3 Genetic factors and ethnic background are considered significant contributors.2 Clinically, PFPT appears as multiple, small, discrete, hyperpigmented papillae located on the anterior part of the dorsal tongue. They are usually asymptomatic and discovered incidentally during routine oral examinations.2 Holzwanger’s classification describes three distinct patterns of PFPT.4 Type I is characterized by a well-defined hyperpigmented patch located on either the anterolateral aspect or the tip of the tongue, consisting of fungiform papillae with hyperpigmentation in each individual papilla. Type II involves hyperpigmentation of 3 to 7 fungiform papillae scattered or loosely clustered on the dorsal surface of the tongue, interspersed with normally pigmented fungiform and filiform papillae. Type III features complete hyperpigmentation of every fungiform papilla on the dorsal surface of the tongue. These patterns may not always be clearly defined, with reported instances of overlap between Type I and Type II.4 PFPT is typically an isolated finding and not associated with systemic conditions. However, cases in association with lichen planus, ichthyosis linearis circumflexa, and Laugier–Hunziker syndrome have been reported.2 Moreover, it is essential to distinguish it from other pigmented lesions that may signify systemic diseases or malignancies. In 2011, Hsiao et al.5 described a dermoscopic cobblestone pattern in PFPT. Later, Mukamal et al.6 observed that the pigmentation in each element of PFPT was predominantly located at the tips and borders of the papillae, gradually fading towards the centre, resembling a ‘rose petal pattern’. Subsequent reports have used the terms cobblestone and rose petal patterns to describe the overall distribution and individual appearance of PFPT, respectively.2,3 Histologically, PFPT shows increased melanin deposition within the epithelium of the fungiform papillae without atypical melanocytes.2,3 Differential diagnoses for PFPT include, eruptive (transient) lingual papillitis, lingua villosa nigra (black hairy tongue), lingual/oral melanotic macule(s), Peutz–Jeghers syndrome, and Laugier–Hunziker syndrome Table 1. PFPT is a benign condition that does not require treatment. Patient education and reassurance are essential to alleviate concerns about the appearance of the lesions.2-6Table 1: Comparative table of pigmented and papillary conditions of the tongueDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.