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Photo Quiz

Pigmented Lesion on the Hard Palate

Keshavamurthy Vinay, MD, DNB, FRCP (Lon.)
Apoorva Sharma, MD, DNB
Manavi Gupta, MD

American Family Physician. 2025;111(3):277-278.

Author disclosure: No relevant financial relationships.

A 59-year-old man presented with a brown-black lesion on the hard palate. The lesion was associated with pain and caused difficulty eating. The lesion started as a small, black-pigmented area 2 years ago and grew gradually. The patient was a 10-pack-year smoker.

Examination of the oral cavity revealed poor oral hygiene and nicotine staining of the teeth. A sharply demarcated, variably pigmented lesion with superimposed nodularity and irregular borders covered a large area of the hard palate (Figure 1). The patient’s upper cervical lymph nodes were bilaterally enlarged (2 cm in diameter) and were mobile, firm, and nontender.

FIGURE 1

QUESTION

Based on the patient’s history and physical examination, which one of the following is the most likely diagnosis?

  • A. Drug-induced melanosis.
  • B. Melanocytic nevus.
  • C. Melanotic macule.
  • D. Palatal melanoma.
  • E. Smoker’s melanosis.

DISCUSSION

The answer is D: palatal melanoma. Oral melanoma usually presents with three key features: a brown-black pigmented plaque, light-brown macular area, and central area with nodularity. Smoking has an unclear relationship with the development of head and neck mucosal melanoma, but it is correlated with increased melanocyte proliferation in the oral mucosa, increasing the risk of pigmented oral lesions.1

Melanoma of the oral cavity comprises 1% of all melanomas, with a higher incidence in men older than 50.2 The most common sites are the maxillary gingiva and hard palate. Pigment variations may include melanotic and amelanotic areas within the same lesion. Other common symptoms include ulceration, pain, and paresis. Early detection through clinical evaluation is crucial for optimal management and improved outcomes.

Drug-induced melanosis can be diffuse or localized. The macular pigmentation may be uniform or vary in color. Some drugs cause a specific pattern of pigmentation, such as hydroxychloroquine triggering palatal mucosal pigmentation.3

Oral melanocytic nevi commonly develop in individuals who are at least 30 years of age. Typically asymptomatic, these lesions may manifest as small, solitary, and well-defined nodules or macules that are brown or blue.4 The lesions can affect any mucosal site but are most common on the hard palate, buccal and labial mucosa, and gingiva.

Melanotic macules are the most common oral mucosal lesions that originate from melanocytes. They are small, solitary, well-defined, and often uniformly pigmented. They tend to be more prevalent in adult women. Melanotic macules can occur on any mucosal site, most often the lower lip, gingiva, and palate.5 Melanotic macules rarely exceed 1 cm in diameter.

Smoking is linked to abnormal pigmentation of the oral mucosa (melanosis) due to nicotine staining and poor oral hygiene. Smoker’s melanosis presents as diffuse, patchy, irregular pigmentation that primarily affects the maxillary and mandibular gingiva. Melanosis is not considered a precancerous condition.6

SUMMARY TABLE

ConditionCharacteristics
Drug-induced melanosisDiffuse or localized; macular pigmentation may be uniform or vary in color
Melanocytic nevusOccurs most often on the hard palate, buccal and labial mucosa, and gingiva; small, solitary, and well-defined nodules or macules; brown or blue
Melanotic maculeOccurs most often on the lower lip, gingiva, and palate; small (< 1 cm), solitary, and well-defined; often uniformly pigmented
Palatal melanomaOccurs most often on maxillary gingiva and hard palate; brown-black pigmented plaque; light-brown macular area; central area with nodularity
Smoker’s melanosisOccurs most often on maxillary and mandibular gingiva; diffuse, patchy, irregular pigmentation

KESHAVAMURTHY VINAY, MD, DNB, FRCP (Lon.); Apoorva Sharma, MD, DNB; and Manavi Gupta, MD, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Address correspondence to Keshavamurthy Vinay at vinay.keshavmurthy@gmail.com.

Author disclosure: No relevant financial relationships.

  1. 1.Seetharamu N, Ott PA, Pavlick AC. Mucosal melanomas: a case-based review of the literature. Oncologist. 2010;15(7):772-781.
  2. 2.McLean N, Tighiouart M, Muller S. Primary mucosal melanoma of the head and neck. Oral Oncol. 2008;44(11):1039-1046.
  3. 3.Kleinegger CL, Hammond HL, Finkelstein MW. Oral mucosal hyperpigmentation secondary to antimalarial drug therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90(2):189-194.
  4. 4.Krengel S. Nevogenesis—new thoughts regarding a classical problem. Am J Dermatopathol. 2005;27(5):456-465.
  5. 5.Kaugars GE, Heise AP, Riley WT, et al. Oral melanotic macules. a review of 353 cases. Oral Surg Oral Med Oral Pathol. 1993;76(1):59-61.
  6. 6.Taybos G. Oral changes associated with tobacco use. Am J Med Sci. 2003;326(4):179-182.

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