What can a stinging sensation in both lips be a sign of?

Stinging Sensation in Both Lips: Differential Diagnosis

A bilateral stinging sensation in the lips most commonly indicates burning mouth syndrome (BMS), contact cheilitis, or allergic angioedema, depending on the clinical context and associated features. 1

Primary Diagnostic Considerations

Burning Mouth Syndrome (Most Likely if Chronic and Isolated)

BMS is characterized by burning, stinging, or itchy sensations affecting the lips (especially bilateral), tongue tip, palate, and buccal mucosa in the absence of visible mucosal abnormalities. 1

• Predominantly affects peri- and post-menopausal women 1
• Symptoms are typically continuous, though some patients experience relief or aggravation with eating 1
• The oral mucosa appears completely normal on examination—this is a key diagnostic feature 1
• Associated features include dry mouth, abnormal taste, depression, and reduced quality of life 1
• Neurophysiological testing suggests a disorder of peripheral nerve fibers with central brain changes 1

Screen for secondary causes before diagnosing primary BMS: 2

• Vitamin deficiencies (particularly vitamin D3, B2, B6, B1, and zinc) 2
• Fasting blood glucose (elevated in 23.7% of BMS patients) 2
• Thyroid function (TSH abnormal in 8.4% of cases) 2
• Oral candidiasis, mucosal lesions, hematological disorders, autoimmune disorders 1
• Medication side effects 1

Contact Cheilitis (If Acute or Exposure-Related)

Contact cheilitis presents with stinging, burning, or itching due to either irritant or allergic contact reactions. 3, 4

• May be caused by cosmetics, lip balms, toothpaste, foods, or occupational exposures 3, 4
• Allergic contact cheilitis involves delayed hypersensitivity (Type IV) reactions 4
• The vermilion border shows visible inflammation, unlike BMS 3, 4
• Identify and remove the offending agent for resolution 3, 4

Allergic Angioedema (If Acute with Swelling)

Bilateral lip swelling with stinging or tingling suggests allergic angioedema, particularly if there is recent exposure to allergens. 5

• Most commonly triggered by bee/wasp stings, medications, or foods (eggs, shellfish, nuts) 5
• Represents a Type I allergic reaction (IgE-mediated) 5
• Often accompanied by urticaria in approximately 50% of cases 5
• Critical warning: Monitor for tongue, laryngeal, or tracheal swelling, which can cause airway obstruction and death 5
• Immediate treatment includes antihistamines and glucocorticoids; epinephrine if laryngeal edema is suspected 5

Post-Traumatic or Post-Herpetic Neuropathic Pain

Neuropathic pain affecting the lips presents with burning, tingling, or stinging sensations following trauma or herpes zoster infection. 1

• Post-herpetic neuralgia occurs at the site of previous herpes zoster, with continuous burning and allodynia 1
• Post-traumatic trigeminal neuropathic pain develops within 3-6 months of dental procedures or facial trauma 1
• Examination may reveal allodynia or other sensory changes 1
• Managed with neuropathic pain medications 1

Less Common but Important Considerations

Kawasaki Disease (Pediatric Emergency)

In children with fever and bilateral lip involvement, consider Kawasaki disease. 1

• Presents with erythema, lip cracking, fissuring, peeling, and bleeding 1
• Requires fever persisting at least 5 days plus 4 of 5 principal features (including lip/oral changes) 1
• Associated with strawberry tongue and diffuse oropharyngeal erythema 1
• This is a cardiovascular emergency requiring immediate recognition and treatment 1

Systemic Diseases and Nutritional Deficiencies

Cheilitis associated with systemic conditions can present with stinging or burning sensations. 3, 6

• Anemia due to vitamin B12 or iron deficiency 3
• Lupus, lichen planus, pemphigus/pemphigoid group 3, 6
• Xerostomia (dry mouth) from various causes 3, 6

Diagnostic Approach

Begin by determining the temporal pattern (acute vs. chronic) and examining the lips for visible abnormalities:

• Normal-appearing lips with chronic bilateral stinging → Consider BMS and screen for secondary causes 1, 2
• Visible inflammation or scaling → Consider contact cheilitis or other inflammatory cheilitis 3, 4
• Acute onset with swelling → Consider allergic angioedema and assess for airway compromise 5
• History of trauma or herpes → Consider neuropathic pain 1
• Pediatric patient with fever → Rule out Kawasaki disease 1

Management Priorities

For BMS: Reassure patients that the condition will not worsen, exclude secondary causes, and consider cognitive behavioral therapy (CBT) with possible neuropathic pain medications 1

For contact cheilitis: Identify and eliminate the causative agent 3, 4

For allergic angioedema: Administer antihistamines and glucocorticoids; use epinephrine immediately if airway involvement is suspected 5

For neuropathic pain: Initiate neuropathic pain medications 1