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Focal epithelial hyperplasia (FEH) is a rare disorder described by Heck primarily as a
disease of Native American children and adolescents, being extremely rare among the
white population.
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The disease is characterized by multiple, soft, circumscribed, sessile, nodular elevations of
the oral mucosa.
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This lesions may be single or clustered; in extreme cases, the confluent lesions may result
in a ”cobblestoned” mucosa.
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Convincing evidence assigned the etiologic role to HPV infection of squamous epithelia
with subtypes 13 and 32.
There is a tendency toward multiple familial cases, suggesting genetic predisposition.
Clinical features
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9-year young girl with multiple asymptomatic
lesions of oral mucosa
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5-10 mm in diameter
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soft rounded or nodular appearance
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similar in color to the surrounding mucosa,
with no inflammatory appearance
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lasting for 7 months
Clinical differential diagnosis
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multiple squamous papillomas
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condylomata acuminata
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neurofibromatosis
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acanthosis nigricans
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multiple hamartoma of Cowden’s syndrome
=> shave-biopsy and histological examination of one lesion
• minimal parakeratosis
• acanthotic epithelium with prominent clubbing and fusion of epithelial ridges
• minimal connective tissue papillae without well-defined projetions of epithelium
• special ballooning type of nuclear degeneration in some
epithelial cells dispersed in all epithelium levels
• typical koilocytic change
• no epithelial dysplasia
• coarse clumped heterochromatin with
pseudomitotic appearance = ”mitosoid bodies”
Mitosoid body = the characteristic feature which enable
the diagnosis of Focal Epithelial Hyperplasia with certainity.
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FEH is a benign asymptomatic condition, requiring only reassurance.
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Ancillary studies for HPV detection are unnecessary in an appropriate clinical context.
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A careful histopathological examination is essential in order to rule out sexually
transmitted viral diseases with medico-legal implications, especially in areas with very
low prevalence of Heck’s disease.