Focal Epithelial Hyperplasia in a Somali Child: A Case Report and Review of Management with Topical Imiquimod

Mohamed A Hersi,1 Mohamud M Abdulkadir,2 Mohamed Abdulkadir Hassan-Kadle,3 Mohamed Hassan Mohamud,4 Abdulkarim Ahmed Mohamud,4 Mohamed Adam Jama51Department of Dermatology, Shafi Hospital, Mogadishu, Somalia; 2Department of Dermatology, Royal Hospital, Mogadishu, Somalia; 3Department of Gastroenterology, Samakaal Hospital, Mogadishu, Somalia; 4Faculty of Medicine and Surgery, Salaam University, Mogadishu, Somalia; 5Neglected Tropical Diseases Unit, Ministry of Health and Human Services, Mogadishu, SomaliaCorrespondence: Mohamed Adam Jama, Ministry of Health and Human Services, Mogadishu, Somalia, Tel +252 613881830, Email somjama3@gmail.comBackground: Focal epithelial hyperplasia (FEH), also known as Heck’s disease, is a rare, benign, contagious condition of the oral mucosa associated primarily with human papillomavirus (HPV) types 13 and 32. It predominantly affects children and adolescents and is often underreported in many regions.Case Presentation: We report the case of an 8-year-old Somali girl who presented with a 3.5-year history of asymptomatic, progressively increasing oral mucosal lesions. Clinical examination revealed multiple soft, flat-topped, verrucous papules involving the lower labial, buccal, lingual mucosa, and gingiva. The patient presented with poor oral hygiene; however, feeding difficulties, malnutrition, systemic symptoms, previous treatment, and similar lesions among family members were absent. A clinical diagnosis of focal epithelial hyperplasia was made (Figure 1). The patient was treated with off-label topical imiquimod 5% cream applied three times weekly at bedtime. After two weeks of therapy, the patient developed local adverse reactions, including mucosal erythema, erosion, crusting, and minor focal bleeding (Figure 2). During this phase, she experienced localized burning discomfort, mild pain, and transient feeding difficulty, which necessitated a temporary 1-week treatment holiday and supportive local care. Following seven weeks of resumption, complete clinical resolution (Figure 3) of the lesions was achieved within ten weeks of total management, with no recurrence observed over a 16-month follow-up period.Conclusion: This case represents the first documented report of focal epithelial hyperplasia in Somalia and highlights the utility of off-label and non-invasive topical imiquimod 5% cream. Increased clinical awareness is essential for accurate diagnosis and appropriate management, particularly in underreported settings.Keywords: focal epithelial hyperplasia, FEH, Heck’s disease, human papilloma virus, imiquimod 5%, Somalia