What is the treatment for multiple blisters on the lips?

Treatment of Multiple Blisters on the Lips

For multiple lip blisters, immediately apply white soft paraffin ointment every 2 hours, perform warm saline mouthwashes daily, and pierce intact blisters at the base with a sterile needle while leaving the blister roof in place as a biological dressing. 1, 2

Immediate Blister Management

Pierce intact blisters at the base with a sterile needle, selecting a site where fluid drains by gravity, but leave the blister roof in situ to act as a biological dressing—never deroof the blister. 2, 1 Gently apply pressure with sterile gauze to facilitate drainage and absorb fluid, and cleanse with antimicrobial solution before and after piercing. 2, 1

For small to medium blisters that are already broken, remove only the fluttering skin and leave the rest intact. 2

Essential Supportive Care (All Cases)

• Apply white soft paraffin ointment to lips every 2 hours for protection and moisturization—this is the cornerstone of lip blister management regardless of etiology. 1, 3, 4
• Perform warm saline mouthwashes daily to reduce bacterial load and promote healing. 1, 3, 4
• Use benzydamine hydrochloride 0.15% oral rinse or spray every 2-4 hours, particularly 20 minutes before eating, for pain relief. 2, 1, 4
• For inadequate pain control, apply viscous lidocaine 2% topically to severe lesions. 1, 4

Diagnosis-Specific Treatment

For Autoimmune Blistering (Pemphigus Vulgaris, Bullous Pemphigoid)

If you suspect autoimmune blistering based on fragile blisters that rupture easily with extensive oral erosions, obtain perilesional skin biopsies for histology and direct immunofluorescence (DIF) to confirm diagnosis before initiating immunosuppression. 2 Apply topical high-potency corticosteroids such as clobetasol propionate 0.05% cream or betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a mouthwash up to four times daily, holding the solution in the mouth for 5 minutes. 2, 1 For extensive involvement, initiate systemic prednisone 0.5-1 mg/kg/day and consult dermatology urgently for steroid-sparing options. 2

For Herpes Simplex Virus

If you see painful vesicles and erosions with a history of recurrent episodes, initiate oral aciclovir 400 mg twice daily for short-term prevention or 200 mg five times daily for acute treatment. 5, 6 The evidence for short-term aciclovir is inconsistent across doses, with 400 mg twice daily showing the strongest preventive effect (RR 0.26,95% CI 0.13 to 0.51). 5 Aciclovir may be administered with or without food, and bioavailability decreases with increasing dose. 6

For Suspected Infection

Obtain bacterial cultures if infection is suspected and administer appropriate antibiotics for at least 14 days. 1, 4 Use antiseptic oral rinse such as 0.2% chlorhexidine gluconate mouthwash twice daily for bacterial superinfection. 2, 1 For fungal involvement (angular cheilitis or candidal infection), use nystatin oral suspension or miconazole oral gel. 1, 3, 4

For Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

If you observe extensive mucocutaneous blistering with skin sloughing, immediately admit the patient, permanently discontinue any suspected causative medications, and administer IV methylprednisolone 1-2 mg/kg. 2 Do not delay ophthalmology referral as ocular involvement requires urgent specialist care. 1

Critical Pitfalls to Avoid

• Never use alcohol-containing mouthwashes (such as Listerine) as they cause additional pain, irritation, and delay healing. 1, 3, 4
• Do not chronically use petroleum-based products on lips as they promote mucosal dehydration and increase secondary infection risk. 1, 4
• Never deroof blisters except in specialized burn centers for severe cases like Stevens-Johnson syndrome. 1
• Do not use topical aciclovir cream for prevention—moderate quality evidence from two RCTs shows it has little effect (pooled RR 0.91,95% CI 0.48 to 1.72). 5

When to Escalate Care

Reevaluate the diagnosis if no improvement occurs after 2 weeks of appropriate treatment. 1, 3 Urgent dermatology referral is required for suspected autoimmune blistering diseases requiring immunosuppression. 1 Immediate specialist care is necessary for extensive mucocutaneous involvement suggesting Stevens-Johnson syndrome. 1

Additional Supportive Measures

Encourage soft diets and use of soft toothbrushes to minimize local trauma. 2 Maintain excellent oral hygiene with toothbrushing to prevent dental decay, which commonly complicates oral blistering. 2 Monitor for and treat oral candidiasis, which frequently develops in patients with chronic oral lesions. 2