What are the potential causes and treatments for blisters on the lips and tongue?

Potential Causes of Blisters on Lips and Tongue

Blisters on the lips and tongue most commonly result from traumatic injury (angina bullosa hemorrhagica), viral infections (herpes simplex), autoimmune blistering diseases (pemphigus vulgaris, Stevens-Johnson syndrome), or contact irritation, with treatment focused on the underlying cause while providing supportive care with white soft paraffin ointment every 2 hours and warm saline rinses. 1, 2

Common Causes

Traumatic/Benign Causes

• Angina bullosa hemorrhagica: Sudden appearance of solitary or multiple hemorrhagic (blood-filled) blisters on oral mucosa, most commonly affecting the soft palate but also appearing on buccal mucosa, lips, and tongue border 3, 4
• These blisters have a dark red to purple appearance, may or may not be painful, and typically break spontaneously releasing bloody content 3
• Healing occurs within 7-10 days without treatment; local trauma is the most likely contributory factor 3, 4
• More common in middle-aged and elderly people with no strong gender predilection 4

Autoimmune Blistering Diseases

• Pemphigus vulgaris: Causes extensive oral erosions and fragile blisters that rupture easily, affecting lips and tongue 5
• Stevens-Johnson syndrome/Toxic epidermal necrolysis: Severe mucocutaneous blistering with oral involvement requiring urgent management 5
• Bullous pemphigoid and cicatricial pemphigoid: Can affect oral mucosa including lips 6

Infectious Causes

• Herpes simplex virus: Causes painful vesicles and erosions on lips and oral mucosa 5
• Candidal infections: May contribute to angular cheilitis with cracking and blistering at lip corners 7
• Bacterial superinfection: Can complicate existing blistering lesions 5

Other Causes

• Epidermolysis bullosa: Genetic blistering disorder affecting skin and mucous membranes from birth 5
• Contact dermatitis/irritant reactions: From topical products, foods, or dental materials 8
• Allergic reactions: Can cause acute lip and tongue swelling with blistering 2

Treatment Approach

Immediate Supportive Care (All Cases)

• Apply white soft paraffin ointment to lips every 2 hours for protection and moisturization 5, 1, 2
• Clean mouth daily with warm saline mouthwashes to reduce bacterial load 5, 1, 2
• Use benzydamine hydrochloride rinse or spray every 2-4 hours, particularly before eating, for pain relief 5, 1

Blister Management

• Pierce intact blisters at the base with sterile needle (bevel facing up) to decompress, selecting a site where fluid drains by gravity 5
• Leave blister roof in situ to act as biological dressing; do not deroof 5
• Gently apply pressure with sterile gauze to facilitate drainage and absorb fluid 5
• Cleanse with antimicrobial solution before and after piercing 5

Cause-Specific Treatment

For Traumatic/Benign Blisters (Angina Bullosa Hemorrhagica):

• No specific treatment required; drainage if symptomatic 3
• Spontaneous resolution within 7-14 days 3, 4

For Autoimmune Blistering Diseases:

• Topical corticosteroids: Betamethasone sodium phosphate mouthwash four times daily or clobetasol propionate 0.05% cream applied to affected areas 5
• Systemic immunosuppression: Required for pemphigus vulgaris and severe cases, managed by dermatology 5
• Topical tacrolimus 0.1% ointment: Applied twice daily for recalcitrant lip lesions 5

For Infectious Causes:

• Viral swabs from eroded areas if HSV suspected 5
• Bacterial/candidal cultures from lesional skin, particularly sloughy or crusted areas 5
• Antiseptic oral rinse (0.2% chlorhexidine digluconate) twice daily for bacterial infection 1, 2
• Antifungal therapy: Nystatin oral suspension or miconazole oral gel for candidal involvement 1, 7

Pain Management

• Topical anesthetic preparations (viscous lidocaine 2%) for inadequate pain control 1
• Oral analgesics (paracetamol/acetaminophen) 20 minutes prior to eating 5
• Barrier preparations such as Gengigel mouth rinse or Gelclair for pain control 5

Critical Pitfalls to Avoid

• Never use alcohol-containing mouthwashes as they cause additional pain and irritation 1, 2
• Do not chronically use petroleum-based products on lips as they promote mucosal dehydration and increase secondary infection risk 7
• Avoid debriding blisters except in specialized burn centers for severe cases like Stevens-Johnson syndrome 5
• Do not delay ophthalmology referral if Stevens-Johnson syndrome suspected, as ocular involvement requires urgent specialist care 5

When to Escalate Care

• Reevaluate diagnosis if no improvement after 2 weeks of appropriate treatment 1, 7
• Urgent dermatology referral for suspected autoimmune blistering diseases requiring immunosuppression 5
• Immediate specialist care for extensive mucocutaneous involvement suggesting Stevens-Johnson syndrome 5
• Consider systemic evaluation for recurrent blistering to rule out underlying hematological or immunological disorders 6, 9