What is the cause and treatment of small white pustules on the inside of my lower lip?

Small White Pustules on the Inside of the Lower Lip

These lesions are most likely Fordyce spots (ectopic sebaceous glands), minor salivary gland cysts, or oral candidiasis, and typically require no treatment unless symptomatic or infected.

Initial Assessment and Diagnosis

The appearance of small white pustules on the inner lower lip requires differentiation between several benign conditions:

• Fordyce spots appear as small (1-3mm), painless, yellowish-white papules representing ectopic sebaceous glands and are completely benign, requiring no treatment 1
• Mucous retention cysts (mucoceles) present as translucent, fluid-filled vesicles that may appear white and typically resolve spontaneously 1
• Oral candidiasis manifests as white plaques or pustules that can be wiped away, leaving an erythematous base, and requires antifungal treatment 2
• Milia are small keratin-filled cysts that appear as firm white papules 1

When to Suspect Infection

If the lesions are symptomatic (painful, burning, or itching) or associated with systemic symptoms, consider:

• Secondary candidal infection, particularly if you have been using topical corticosteroids, have diabetes, or are immunocompromised 2
• Bacterial superinfection if there is surrounding erythema, warmth, or purulent drainage 3

Treatment Approach

For Asymptomatic Benign Lesions (Most Common)

• No treatment is necessary for Fordyce spots or small mucous cysts, as these are normal anatomical variants 1
• Reassurance is the primary intervention, as these lesions pose no health risk 1

For Symptomatic or Infected Lesions

Pain management:

• Use benzydamine hydrochloride oral rinse or spray every 2-4 hours for pain control if lesions are uncomfortable 1
• Apply viscous lidocaine 2% sparingly to affected areas if benzydamine provides inadequate relief, but use cautiously to avoid accidental ingestion 1

Oral hygiene:

• Perform daily warm saline mouthwashes to reduce bacterial colonization and promote healing 1, 4
• Consider 0.2% chlorhexidine digluconate mouthwash twice daily if secondary infection is suspected 1

If candidal infection is confirmed:

• Treat with nystatin oral suspension or miconazole oral gel as first-line antifungal therapy 1
• For refractory cases, fluconazole 150mg single dose may be considered, though this is typically reserved for more extensive oral candidiasis 2

For Persistent or Concerning Lesions

Topical corticosteroids for inflammatory conditions:

• If lesions are part of an inflammatory process (such as lichen planus or pemphigus), use betamethasone sodium phosphate mouthwash as a rinse-and-spit solution 1-4 times daily 1
• Alternatively, clobetasol propionate 0.05% ointment can be applied directly to affected areas 1, 5

Protective measures:

• Apply white soft paraffin ointment to the lips every 2 hours to prevent drying and cracking 1, 4
• Use mucoprotectant mouthwashes (such as Gelclair) three times daily to protect ulcerated surfaces 1

Red Flags Requiring Dermatology Referral

• Lesions that persist beyond 2-3 weeks despite conservative management 6
• Progressive enlargement or coalescence of lesions 7
• Associated systemic symptoms (fever, malaise, lymphadenopathy) 3
• Lesions that are indurated, fixed, or ulcerated, raising concern for malignancy 3, 8
• Concurrent genital or skin lesions suggesting systemic disease (pemphigus, lichen planus, lichen sclerosus) 3, 5, 8

Common Pitfalls to Avoid

• Do not biopsy or excise benign Fordyce spots, as this creates unnecessary scarring and the lesions are harmless 1
• Avoid systemic corticosteroids for any oral lesions, as they can trigger flares of underlying conditions and promote secondary infections 7
• Do not use chlorhexidine mouthwash for prolonged periods without indication, as evidence for prevention is limited and it can cause staining 1
• Avoid overuse of topical anesthetics like lidocaine, as accidental ingestion can lead to toxicity 1, 4