How should I manage a patient presenting with lip swelling?

Management of Lip Swelling

First, immediately assess for anaphylaxis by checking for respiratory compromise (dyspnea, wheeze, stridor), hypotension, or multi-system involvement—if any are present, inject intramuscular epinephrine 0.3-0.5 mg into the lateral thigh immediately and activate emergency medical services. 1

Immediate Assessment Algorithm

Step 1: Rule Out Life-Threatening Anaphylaxis

Anaphylaxis is highly likely if the patient has acute lip swelling PLUS any of the following: 2

• Respiratory symptoms: dyspnea, wheeze, bronchospasm, stridor, or reduced oxygen saturation 2
• Cardiovascular compromise: systolic BP <90 mmHg, >30% drop from baseline, syncope, or hypotonia 2
• Multi-system involvement: skin changes (hives, flushing) PLUS respiratory OR cardiovascular symptoms 2
• GI symptoms: persistent crampy abdominal pain or vomiting after allergen exposure 2

If anaphylaxis is present:

• Administer epinephrine 0.3-0.5 mg IM in the lateral thigh immediately 1
• Repeat epinephrine after 5-10 minutes if no response and EMS is delayed 1
• Fatal reactions are associated with delayed epinephrine administration 2
• Transport to emergency department for observation (reactions can be biphasic) 2

Critical pitfall: Never delay epinephrine if anaphylaxis is suspected—this is the leading cause of preventable mortality 2, 1

Non-Anaphylactic Lip Swelling Management

Step 2: Initiate Foundational Lip Care (All Patients)

Apply white soft paraffin ointment to the lips immediately, then every 2 hours throughout the acute phase for barrier protection and moisture retention. 3, 1, 4

Step 3: Implement Supportive Care Measures

• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 3, 1, 4
• Apply benzydamine hydrochloride oral rinse or spray every 2-4 hours (especially before eating) for anti-inflammatory effect and pain control 3, 1, 4
• Use mucoprotectant mouthwash (e.g., Gelclair) three times daily if mucosal ulceration is present 3, 1, 4

Step 4: Determine Etiology and Add Specific Treatment

For Allergic Angioedema (Non-Anaphylactic)

Angioedema presents as well-demarcated subcutaneous swelling that typically resolves within 72 hours. 5, 6

• Administer oral H1 antihistamines (e.g., cetirizine 10 mg daily or diphenhydramine 25-50 mg every 6 hours) 5, 6
• Add oral corticosteroids for large local reactions (e.g., prednisone 40-60 mg daily for 3-5 days) 2, 3
• Consider adding H2 antihistamines if H1 antihistamines alone are inadequate 6

Note: While controlled studies proving efficacy are lacking, this approach is standard practice for large local reactions. 2

For Angular Cheilitis (Cracks at Lip Corners)

This typically involves both Candida infection and inflammation. 4

• Apply combination antifungal-corticosteroid therapy as first-line treatment 4
• Antifungal component: 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 4
• Corticosteroid component: betamethasone sodium phosphate 0.5 mg in 10 mL water as rinse-and-spit four times daily OR clobetasol propionate 0.05% mixed with Orabase applied directly to affected areas 4

For Inflammatory/Eczematous Cheilitis

• Apply topical corticosteroids (betamethasone or clobetasol) four times daily for initial inflammation control 3, 4
• For recalcitrant cases or when corticosteroid side effects are a concern, switch to topical tacrolimus 0.1% ointment twice daily 4

For Suspected Infectious Causes

• Obtain bacterial and fungal cultures if secondary infection is suspected 3, 4
• Administer appropriate antibiotics for at least 14 days if bacterial infection is confirmed 3

Pain Management Escalation

If benzydamine is inadequate for pain control: 3, 1, 4

• Use viscous lidocaine 2%, 15 mL per application as topical anesthetic 3, 1, 4
• For severe oral discomfort, use cocaine mouthwashes 2-5% three times daily 3, 1, 4

Critical Pitfalls to Avoid

• Never use alcohol-containing mouthwashes—they cause additional pain and irritation 3, 1, 4
• Do not chronically use petroleum-based products alone—they promote mucosal cell dehydration and create an occlusive environment that increases secondary infection risk 3, 4
• Never delay epinephrine if respiratory symptoms develop—this is associated with increased mortality 2, 1

Reassessment Timeline

• Immediate reassessment required if respiratory symptoms develop or worsen—activate EMS 1
• Reevaluate diagnosis after 2 weeks if no improvement with appropriate treatment 3, 1, 4
• Consider underlying systemic conditions (hereditary angioedema, Crohn's disease, sarcoidosis, immunosuppression, nutritional deficiencies, diabetes) in persistent cases 3, 4, 7
• Obtain bacterial and fungal cultures if secondary infection is suspected 3, 4

Special Considerations

Immunocompromised patients require more aggressive and prolonged therapy due to increased risk of secondary infections. 3

Hereditary angioedema should be considered in patients with recurrent lip swelling, particularly those with a family history—these patients require specialized treatment with C1 inhibitor replacement, not standard antihistamines. 3

Drug-induced angioedema (especially ACE inhibitors) requires immediate discontinuation of the offending agent. 5, 6