What is the diagnosis and management for red spots on the tongue?

Red Spots on the Tongue: Diagnosis and Management

Primary Diagnostic Considerations

Red spots on the tongue most commonly represent one of four conditions: geographic tongue (benign migratory glossitis), erythematous candidiasis, transient lingual papillitis, or median rhomboid glossitis. 1

Key Clinical Features to Distinguish Diagnoses

Geographic tongue presents as irregular red patches with white borders that migrate across the tongue surface over days to weeks, caused by loss of filiform papillae. 1, 2 This condition:

• Requires no treatment as it is benign and self-limiting 1
• May be asymptomatic or cause mild burning sensation 2
• Diagnosis is clinical based on the characteristic migratory pattern 1

Erythematous candidiasis appears as red patches without white plaques, typically on the palate or diffusely on the tongue. 3 This differs from pseudomembranous candidiasis (oral thrush), which shows creamy white plaques that scrape off. 3 Key distinguishing features include:

• Associated risk factors: immunosuppression (HIV with CD4+ <200 cells/μL), corticosteroid use (including inhaled steroids), or radiation therapy 4
• Caused primarily by Candida albicans, though non-albicans species (C. glabrata, C. dubliniensis, C. krusei) occur with fluconazole resistance 4

Transient lingual papillitis shows pronounced, enlarged fungiform papillae on the anterior tongue with a red appearance and possible tooth impressions on lateral borders. 5 This condition:

• Has unknown etiology, though local irritation may contribute 5
• Regresses spontaneously within weeks without treatment 5
• Is very common but often unrecognized 5

Median rhomboid glossitis presents as a red, demarcated area in the midline posterior tongue. 6 This lesion:

• Is usually associated with candidal infection 1, 6
• Responds to topical or oral antifungal therapy 1, 6

Management Algorithm

Step 1: Assess for Candidal Infection

If red patches are present with risk factors for candidiasis (immunosuppression, steroid use, poor oral hygiene), initiate antifungal therapy first. 7, 4

For erythematous candidiasis or median rhomboid glossitis:

• First-line: Oral fluconazole 200-400 mg daily for 14-21 days 7
• Alternative topical options: Nystatin oral suspension 100,000 units four times daily for 1 week, or miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 8
• For fluconazole-refractory disease: Itraconazole solution 200 mg daily OR voriconazole 200 mg twice daily for 14-21 days 7

Step 2: Evaluate for Geographic Tongue

If red patches have white borders and migrate over time without other symptoms, diagnose geographic tongue and reassure the patient that no treatment is needed. 1, 2

Step 3: Consider Transient Lingual Papillitis

If enlarged fungiform papillae are visible on the anterior tongue with soreness, diagnose transient lingual papillitis and provide reassurance that spontaneous resolution occurs within weeks. 5

Step 4: Rule Out Serious Pathology

If ulceration is present, white plaques do not scrape off, or lesions persist despite antifungal treatment, obtain a biopsy to exclude squamous cell carcinoma or premalignant leukoplakia. 3, 1 Warning signs include:

• Persistent ulceration without white plaques 3
• Non-healing lesions after 2 weeks of appropriate therapy 8
• History of tobacco use, alcohol consumption, or HPV infection 7

Special Considerations

In immunocompromised patients, more aggressive and prolonged antifungal therapy may be required. 8 Effective antiretroviral therapy is the best prophylaxis against recurrent oral candidiasis in HIV-infected patients. 4

Atrophic glossitis (smooth, red tongue due to papillae loss) requires evaluation for nutritional deficiencies of iron, folic acid, vitamin B12, riboflavin, or niacin, and resolves with correction of the underlying deficiency. 1

Critical Pitfall to Avoid

Do not confuse benign geographic tongue with erythematous candidiasis. Geographic tongue has characteristic white borders and migrates, while candidal infection presents with uniform red patches and responds to antifungal therapy. 3, 1 If uncertain, a trial of antifungal therapy for 2 weeks can help differentiate: candidal lesions will improve, while geographic tongue will not respond. 8, 6