Dermatol Clin 21 (2003) 123 – 134

Glossitis and other tongue disorders

Julie A. Byrd, MD, Alison J. Bruce, MD*, Roy S. Rogers III, MD
Department of Dermatology, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA

The tongue can often provide clinical clues to the thyroid gland. The foramen cecum forms the apex
systemic conditions and demonstrate a number of of a V-shaped groove known as the sulcus terminalis,
conditions unrelated to other systemic disease. which divides the anterior two thirds from the pos-
Because it is visible to patients easily, they may terior one third of the dorsal tongue (Fig. 1). The
present for evaluation of a variety of incidentally anterior portion embryologically develops from the
noted disorders. Understanding normal anatomy and first branchial arch and is innervated by a branch of
architecture and reassuring patients is often all that is the VII nerve, the corda tympani. The posterior third
necessary. When tongue abnormalities are present, of the tongue develops from the second and third
however, recognizing them as benign or associated brachial arch and is supplied by the glossopharyngeal
with other disease is a valuable clinical skill. Exam- (IX) nerve. The posterior portion is known as the
ination of the tongue and oral mucosa is an essential base or root of the tongue.
part of a physical examination. Clinicians need to The distinctive texture and appearance of the
recognize and know a spectrum of disorders affecting dorsal tongue are caused by papillae, which are
the tongue. This article reviews a number of tongue adapted for mastication and taste. Three types of
conditions encountered including furred tongue, papillae are present on the anterior two thirds of
black hairy tongue, smooth tongue, fissured tongue, the tongue serving differing functions. The filiform
median rhomboid glossitis, geographic tongue, sub- papillae are the most prevalent papillae uniformly
lingual varices, oral hairy leukoplakia (OHL), her- distributed on the dorsum. They are 1- to 2-mm thin
petic geometric glossitis, and macroglossia. papillae without taste buds. The pointed filiform
papillae morphologically provide the rough texture
and facilitate mechanical function of licking and
Anatomy mastication. The fungiform papillae are scattered
on the anterior tongue, mostly on the tip and lateral
The tongue is a muscular organ necessary for margins. Clinically they are identified by their red
speech, taste, food manipulation, and mastication. It color and dome or mushroom shape. The circum-
is composed largely of skeletal muscle. The intricate vallates are the largest papillae (3 to 10 mm) but the
movements of the tongue are made possible by a least prevalent. They are present in a single row
complex arrangement of intersecting muscles in mul- distal and parallel to the sulcus terminalis. Both the
tiple directions. The hypoglossal (XII) nerve supplies fungiform and circumvallate papillae have taste
motor innervation to these muscles. buds. The posterior tongue lacks papillae and is
On the dorsum, the tongue is divided centrally by composed of the lingual tonsils, lymphoid tissue,
the median sulcus. The median sulcus begins prox- and mucin secretory glands covered by a thin
imal to the apex of the tongue and ends at the mucosal epithelium.
foramen cecum, which is the embryonic origin of The ventral tongue contains the lingual frenulum,
lingual veins, and the submandibular glandular ducts.
* Corresponding author. The frenulum attaches the ventral tongue to the floor
E-mail address: bruce.alison@mayo.edu (A.J. Bruce). of the mouth extending from the ventral tongue tip to

0733-8635/03/$ – see front matter D 2003, Elsevier Science (USA). All rights reserved.
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124 J.A. Byrd et al. / Dermatol Clin 21 (2003) 123–134

Fig. 2. Protrusion of the tongue to one side to enable

adequate examination of the lateral margin. Using a tongue
blade to retract the cheek allows better visualization.

the tongue to one side enabling examination of the

opposite lateral margin (Fig. 2). A tongue blade may
Fig. 1. Anatomy of the dorsal tongue. be useful for better visualization. Have the patient
elevate the tip of the tongue to the roof of the mouth
to examine the ventral surface. Note any nodules or
the mid-mandible. The lingual veins and submandib- varicosities on the ventral tongue. Palpation of the
ular ducts run parallel to the frenulum. entire tongue is a crucial part of the examination. Use
gauze to grasp the tongue and allow manipulation.
Particularly note the texture, consistency, and any
Physical examination tenderness of the tongue. Nodularity or masses within
the tongue may be worrisome for cancer, and tender
A thorough examination of the tongue is an areas may raise concern for infection.
integral part of the physical examination and may
provide clues to systemic disorders [1]. Good light-
ing, preferably with natural light or a hand-held light, Furred tongue
is important for adequate examination. A systematic
approach to the examination, beginning with inspec- Clinical manifestations
tion of all aspects of the tongue (dorsum, lateral
margins, and ventral surface) and concluding with The furred tongue is a common benign condition
palpation of the entire surface from the tip prox- caused by hypertrophy of the filiform papillae. Clin-
imally, provides a thorough and complete examina-
tion. Initially note the shape and color of the tongue
as it rests in the mouth. The presence of notching on
the lateral margins of the tongue (also known as a
scalloped tongue) is indicative of macroglossia or a
tongue thrusting habit, because the pressure from the
teeth on the tongue creates the notches. The normal
tongue is pink in color and the papillae easily
visualized. Many conditions present with alterations
in color or texture of the tongue and clinicians should
be familiar with normal appearance to appreciate best
changes to normal architecture.
Protrusion of the tongue elicits any muscular or
neurologic abnormalities, such as lateral deviation
and fasciculations, and also allows for better visu- Fig. 3. Furred tongue. The white ‘‘fur’’ on the middle of the
alization of the dorsal tongue. Next, inspect the lateral dorsal tongue is caused by hypertrophy and hyperplasia of
margins on the tongue by having the patient protrude the filiform papillae.
 J.A. Byrd et al. / Dermatol Clin 21 (2003) 123–134 125

Table 1
Furred tongue
Clinical White coating of tongue
Etiology Hypertrophy of
filiform papillae
Predisposition Mouth breathing, dehydration,
fever, or smoking
Prognosis Benign
Diagnosis Clinical
Treatment Brush tongue with dentifrice

ically it presents as a complete or partial white coating

of the anterior tongue giving the appearance of thin
white fur for which the condition is named (Fig. 3,
Table 1). The furring may vary in color from white to
brown [2]. Particularly in smokers, the fur may take on
a tan color. It typically involves the middle portion of
the tongue, with other areas in the mouth unaffected.
Fig. 4. Black hairy tongue. The appearance of black hair of
The filiform papillae become hypertrophied and the tongue is created by filiform papillae hyperplasia with
hyperkeratotic because of a decreased rate of des- trapped normal flora and bacterial metabolic products.
quamation. The desquamated epithelial debris is
trapped between the enlarged filiform papillae. The filiform papillae are elongated with pointed ends and
condition is seen commonly in otherwise healthy have a brown to black coating, appearing to be
individuals who are smokers, mouth breathers, or with covered with a thick brown-black hair. This condition
poor oral hygiene. Patients on a soft diet lacking is caused by hyperplasia and hyperkeratosis of the
roughage may also develop fur. In the ill patient, the filiform papillae. The dark color results from normal
furred tongue is usually caused by dehydration or flora and bacteria that become trapped in the hyper-
fever. The furred tongue is usually asymptomatic, plastic papillae. Because only the filiform papillae are
although halitosis can result from degeneration of food affected, the characteristic brown-black discoloration
and other debris trapped within the plaque of fur. occurs distal to the sulcus terminalis. Prevalence has
been report as 3.4% of the population [3]. Most
Diagnosis and treatment patients are asymptomatic but some experience hal-
itosis, abnormal taste, or nausea presumably because
The diagnosis is based on clinical findings and of the elongated papillae. Similar to the furred tongue,
biopsy is not necessary. Smoking cessation, rehydra- smoking and poor oral hygiene have been implicated
tion, resolution of febrile illness, and correction of as causative. It may also develop following antibiotic
mouth breathing, respectively, are important manage- treatment, typically penicillin and tetracycline [5]. The
ment steps in otherwise well patients. Treatment black pigment represents porphyrins, which are meta-
includes increasing roughage and fiber in the diet to bolic products of oral bacteria, most likely caused by
promote desquamation. Brushing the tongue with 5 to alteration in the normal mouth flora as a consequence
15 strokes daily using a soft-bristled toothbrush and
dentifrice is helpful.
Table 2
Black hairy tongue
Clinical Brown-black coating
Black hairy tongue
of tongue
Etiology Bacteria and pigmented
Clinical manifestations metabolites trapped among
hyperplastic filiform papillae
The black hairy tongue is also known as lingua Predisposition Antibiotic use, smoking, or
villosa nigra and hyperkeratosis lingual. Patients poor oral hygiene
present with a dark brown to black tongue, which Prognosis Benign
also may appear hairy (Fig. 4, Table 2). As with the Diagnosis Clinical
furred tongue, the involved area is usually the middle Treatment Brush tongue with 1% – 2%
anterior two thirds of the dorsal tongue [3,4]. The hydrogen peroxide
126 J.A. Byrd et al. / Dermatol Clin 21 (2003) 123–134

of antibiotic therapy. Long-term use of antacids and Table 3

oxidizing mouthwashes has also been reported to Smooth tongue
cause black hairy tongue [4]. Chronic Pepto-Bismol Clinical Smooth glossy tongue
use can produce a similar clinical picture. Etiology Atrophy of filiform or
fungiform papillae
Diagnosis and treatment Predisposition Systemic: nutritional deficiency,
malabsorption, Riley-Day syndrome
Prognosis Varies with etiology
Biopsy is not necessary for diagnosis. Treatment
Diagnosis History, examination, and
involves brushing the tongue with 1% to 2% hydro- laboratory work-up
gen peroxide. As with furred tongue, increasing Treatment Correct underlying etiology, and
roughage, correction of mouth breathing, and smok- bland diet
ing cessation are important therapeutic interventions.
Avoiding further antibiotics allows the normal flora to
reconstitute, diminishing the prevalence of the pig- Correction of the nutritional deficiency results in rapid
ment-producing microflora. regeneration of papillae. The smooth tongue can also
be a manifestation of syphilis infection, amyloidosis,
celiac disease, or cardiac failure. Sjögren’s syndrome,
Smooth tongue Plummer-Vinson syndrome, and Riley-Day dysauto-
nomia syndrome can present with smooth tongue.
Clinical manifestations Riley-Day syndrome is an autosomal recessive her-
editary sensory and autonomic neuropathy consisting
The smooth tongue presents as a smooth glossy of labile blood pressure, lack of deep tendon reflexes,
tongue (Fig. 5, Table 3). This condition is also known decreased perception of temperature and pain, lack of
as bald tongue and atrophic glossitis. Patients usually tearing, and absence of filiform papillae [7,8]. This
complain of a burning sensation or painful tongue. disorder is differentiated from the other sensory and
On inspection, the tongue lacks the normal rough autonomic neuropathies by the lack of filiform papil-
appearance created by the papillae. The background lae. A thorough history, physical examination, and
color may be red, pink, or magenta [2]. Biopsy shows laboratory evaluation should be directed to detect
atrophy of the filiform papillae accounting for the systemic disease. Treatment involves correction of
smooth appearance. With time fungiform papillae underlying systemic cause if possible. Symptomatic
may also atrophy [6]. treatment with a soft bland diet is necessary because
patients usually complain of a painful sore tongue.
Diagnosis and treatment

This condition is the manifestation of a system- Fissured tongue

ic disorder, such as malabsorption or nutritional defi-
ciencies of iron (anemia), folic acid, vitamin B12 Clinical manifestations
(pernicious anemia), riboflavin, or niacin (pellagra).
This condition is also called lingua plicata. Older
terminology includes scrotal tongue. The authors
discourage this descriptor. The condition presents as
a central long deep groove on the dorsal tongue with
multiple irregular side grooves (Fig. 6, Table 4). The
fissures can occur elsewhere on the dorsal tongue,
including the lateral margins. Papillae are present in
the fissures up to a limited depth. In marked fissuring,
the deeper portions may be without papillae contrib-
uting to bacterial overgrowth and inflammation [9].
The fissured tongue is normal with aging. It is the
most common developmental defect of the tongue.
Prevalence has been reported in dental studies to be
5% to 11.4% [3,10]. The fissures are typically asymp-
Fig. 5. Smooth tongue. Atrophy of filiform papillae leaving tomatic unless inflamed because of trapped food
the tongue with a smooth glossy appearance. debris, bacterial overgrowth, and low-grade infection.
 J.A. Byrd et al. / Dermatol Clin 21 (2003) 123–134 127

patients, and unless the history suggests otherwise no

additional evaluation is needed. The condition is
diagnosed clinically. Patients should be reassured of
its benign nature. Treatment involves brushing the
tongue (5 to 15 strokes) with dentifrice and a soft
bristled toothbrush after meals and before sleeping to
prevent buildup of food debris and bacteria in the
fissures, which can cause halitosis. If pain is a
problem, a topical anesthetic, such as viscous lido-
caine, can be applied before meals.

Median rhomboid glossitis

Clinical manifestations

Median rhomboid glossitis has also been termed

chronic candidiasis and central papillary atrophy of
the tongue. It is uncommon with a prevalence less
than 1% [16]. Men are affected three times more
often than women. The condition clinically appears
as a rhomboid-shaped plaque in the central tongue
with surface changes of hypertrophy or atrophy
(Fig. 7, Table 5) [17,18]. Patients may complain of
slight burning sensation on the tongue when eating
spicy foods, although most are asymptomatic. On
Fig. 6. Fissured tongue. Deep fissures in the central tongue examination a flat or raised sharply circumscribed
with multiple fissures branching off in an irregular pattern. red to red-white patch is present on the midline of the
tongue anterior to the foramen cecum. On palpation
the tongue may feel normal or firm. The involved
Diagnosis and treatment tongue surface is smooth. Histology reveals an
absence of filiform papillae and dense chronic
The fissured tongue has been associated with inflammation. Candidal organisms have been report-
Down syndrome, acromegaly, Sjögren’s syndrome, ed in a large number of cases [17,19].
psoriasis, geographic tongue, and Melkersson-Rosen-
thal syndrome. Melkersson-Rosenthal syndrome is a
rare entity characterized by relapsing orofacial edema
(usually lower lip edema); facial nerve palsy; and
severe fissuring of the tongue [11 – 15].
The fissured tongue is usually an incidental find-
ing. It is a common condition, particularly in older

Table 4
Fissured tongue
Clinical Central long deep groove with
multiple irregular side grooves
Etiology Developmental defect
Associations Age, Down syndrome, psoriasis,
Melkersson-Rosenthal syndrome
Prognosis Benign
Diagnosis Clinical
Treatment Brush tongue with dentifrice to
Fig. 7. Median rhomboid glossitis. The central tongue shows
keep grooves clean
smooth, red to red-white plaque without filiform papillae.
128 J.A. Byrd et al. / Dermatol Clin 21 (2003) 123–134

Table 5 ically. No treatment is necessary. Topical antifungals

Median rhomboid glossitis (nystatin suspension applied twice daily, or clotrima-
Clinical Central rhomboid-shaped zole [Mycelex troches]) can result in temporary
hyperkeratotic or erythematous plaque improvement but complete resolution is rare.
Etiology Chronic candidiasis; When median rhomboid glossitis is found in
?developmental anomaly association with palatal inflammation corresponding
Prognosis Benign to contact with the involved area on the tongue,
Diagnosis Viral culture, fungal smear, biopsy
immunosuppression should be suspected [19]. This
to exclude malignancy on occasion
condition is called candidal infection of the tongue
Treatment None; antifungals if symptomatic
and nonspecific inflammation of the palate. It is
considered a thumbprint of AIDS [4], so HIV status
The cause is unknown. Until recently, it was should be sought in these patients.
thought to be caused by congenital persistence of the
tuberculum impar, although in general the changes are
not present at birth. The tuberculum impar is visible Geographic tongue
when a fusion defect of the two lateral portions of the
posterior tongue occurs. Lately, it has been associated Clinical manifestations
with chronic Candida infection [17,19 – 21], with one
author reporting 90% of patients with median rhom- Geographic tongue has multiple other names
boid glossitis demonstrating candidal infection [21]. including benign migratory glossitis, erythema
Characteristically the patients lack evidence of candi- migrans, and glossitis areata migrans. Patients present
dal infection on other mucosal surfaces in the mouth. with erythematous and white patches on the dorsum of
Although the presence of Candida has been suggested the tongue (Fig. 8, Table 6). The red patches lack
to play an etiologic role, the mechanism is unclear. The papillae and are atrophic, whereas the white areas have
development of the abnormality in adulthood, how- either normal or hypertrophied papillae. The patches
ever, does argue against a congenital defect. Some are irregular and sharply demarcated resembling a
clinicians or patients may be concerned about the map, hence the terminology. Patches may occur on
possibility of oral cancer. If this is a significant the lateral margins or ventral tongue. Characteristically
concern, a biopsy to exclude squamous cell carcinoma the plaques vary in location and shape hourly to daily.
may be indicated. Prevalence ranges from 1% to 14.4%, affecting all
age groups and females more often than males
Diagnosis and treatment [4,9,10,16,22,23]. A familial history of this disorder
may be present. This benign inflammatory disorder is
The condition is benign with no specific systemic usually asymptomatic unless fissures are present.
association. Fungal cultures or fungal smears may Forty percent of patients with geographic tongue have
confirm the presence of Candida but are not essential fissured tongue [19]. When fissures are present pain
for diagnosis, because the diagnosis is made clin- may occur if they are inflamed.

Diagnosis and treatment

Diagnosis is usually made clinically by the typical

appearance of the lesions and their migratory nature.

Table 6
Geographic tongue
Clinical Migratory erythematous and white
patches on tongue
Etiology Denuded papillae and hypertrophied
papillae; disorder of keratinization
Predisposition Unknown, associated with psoriasis
and atopy
Prognosis Benign
Fig. 8. Geographic tongue. Erythematous areas of denuded
Diagnosis Clinical
papilla with surrounding white rim in an irregular pattern.
Treatment Reassurance
Characteristically this pattern changes hourly to daily.
 J.A. Byrd et al. / Dermatol Clin 21 (2003) 123–134 129

Fig. 10. Subungual varices. Vascular dilatations of the

ventral tongue and lateral margins.
Fig. 9. Histopathology of the geographic tongue demon-
strating acanthosis and hyperkeratosis of the epithelium with should be sure, however, to exclude hereditary hem-
intraepithelial neutrophilia (Hematoxylin and eosin stain, orrhagic telangiectasia (Osler-Weber-Rendu disease).
original magnification  40). The lesions of this syndrome are small pinpoint
telangiectatic mats that occasionally appear as 1- to
2-mm papules. Varices are generally larger, compress-
On biopsy the erythematous patches are devoid of
ible papules and nodules. Blue rubber bleb nevus
papillae and the white patches contain hypertrophied
syndrome and the superior vena cava syndrome
papillae. Some patients with a geographic tongue have
should also be considered in the differential but are
a mucosal variant of pustular psoriasis. Histology
usually excluded with a thorough clinical evaluation.
reveals areas with absent granular layer, acanthosis,
and subcorneal neutrophilic abscesses consistent with
the features of pustular psoriasis (Fig. 9) [24]. Geo-
Oral hairy leukoplakia
graphic tongue has been associated with atopy [25],
although it can occur as an isolated abnormality. This
Clinical manifestations
is a self-limited disorder usually lasting several
months to years. Treatment is reassurance. If patients
Oral hairy leukoplakia is the term used to describe
are experiencing discomfort with spicy, sour, or salty
a benign white lesion on the lateral margins of the
foods these should be avoided. Palliative therapy with
tongue. It is traditionally seen in immunosuppressed
antiyeast treatment, topical corticosteroids, or topical
patients infected with Epstein-Barr virus (EBV) [26].
analgesics may be helpful [23].
OHL presents as a white linear hairy appearance on
the lateral margin of the tongue or buccal mucosa
(Fig. 11, Table 8). A thorough examination of the
Sublingual varices
lateral margin is essential for diagnosis. Early lesions
appear corrugated because there are white plaques on
Clinical manifestations
the ridges of the lateral tongue and erythematous
mucosa in the troughs created by muscle attachments.
Sublingual varices are benign vascular dilatations.
With time the lesions become completely white. The
Patients may note a discoloration of the ventral
white hyperkeratotic patches are adherent and do not
tongue (Fig. 10, Table 7). In this condition the lingual
scrape off with a tongue blade or gauze. These lesions
veins become dilated and tortuous, causing the blue
nodularity on the ventral tongue. The varices are
usually asymptomatic and incidentally noticed by Table 7
the patient. Ten percent of the population over the Sublingual varices
age of 40 is affected. Clinical Blue ventral tongue varices
Etiology Vascular dilatation
Diagnosis and treatment Predisposition Increasing age
Prognosis Benign
No clinical significance has been established. No Diagnosis Clinical
Treatment None; reassurance
treatment but reassurance is necessary. The clinician
130 J.A. Byrd et al. / Dermatol Clin 21 (2003) 123–134

Fig. 11. Oral hairy leukoplakia. White corrugated plaques on Fig. 12. Formalin fixed, parafin embedded tissue demon-
lateral tongue that are not removable. strating Epstein-Barr virus infection in OHL using in situ
hybridization (original magnification  60).

can become secondarily infected with Candida but suppression, HIV testing and an evaluation for other
even then the hyperkeratosis remains adherent. His- immunosuppression states should be pursued.
tology reveals acanthosis, parakeratosis, and irregular
projections of keratin [26,27]. Vacuolated keratino- Diagnosis and treatment
cytes are present in the spinous layer and EBV has
been identified in these cells [28,29]. Diagnosis is made clinically with supportive
Oral hairy leukoplakia has been reported almost histology and confirmation of EBV infection. OHL
exclusively in immunodeficient patients. Originally it is usually asymptomatic and no treatment is neces-
was believed only to affect homosexual HIV-positive sary. Without treatment the lesions persist. Oral
men but OHL has been reported in other HIV patients
and in patients with other causes of immunodeficiency,
such as organ transplant recipients [30 – 33]. The
lesions appear as HIV progresses, yet no association
with decreasing CD4 counts has been observed [34].
More than one third of AIDS patients develop OHL,
but the disorder is not limited to HIV patients. Other
immunosuppressed patients may be affected, particu-
larly renal and bone marrow transplant recipients
[31,35,36]. Infection with EBV has been reported in
the plaques of OHL [26,35]. In fact, it has been
proposed that identification of EBV DNA by in situ
polymerase chain reaction be used for diagnosis
because in one study a 17% false-positive rate was
found by using clinical criteria alone (Fig. 12) [37,38].
If OHL is found in patients without known immuno-

Table 8
Oral hairy leukoplakia
Clinical Adherent white hairy
lesions on lateral tongue
margin or buccal mucosa
Etiology Epstein-Barr virus infection
Predisposition Immunosuppression
Prognosis Benign
Diagnosis Clinical
Fig. 13. Herpetic geometric glossitis. A tender shiny patch is
Treatment None, topical tretinoin,
located on the central tongue. Often they are in a geometric
oral antivirals, antiretrovirals
pattern, but as in this case not always.
 J.A. Byrd et al. / Dermatol Clin 21 (2003) 123–134 131

Table 9 Table 10
Herpetic geometric glossitis Macroglossia
Clinical Painful linear fissures Clinical Tongue proportionally larger than jaw
Etiology Herpes simplex virus Etiology Congenital or acquired
Predisposition Immunosuppression Predisposition Varies
Prognosis Benign Prognosis Varies
Diagnosis Viral culture, Tzanck smear, biopsy Diagnosis History, examination, laboratory tests,
Treatment Oral antiviral therapy and biopsy
Treatment Depends on etiology

antivirals, topical tretinoin, and antiretrovirals can

provide temporary remission. If secondarily infected geometric glossitis usually resolves in 3 to 12 days
with Candida, antifungal treatment may provide [39]. Symptomatic treatment with a bland, soft diet
symptomatic relief. and local anesthesia may be necessary until healing
occurs. The condition may be recurrent. It usually
responds to antiviral therapy after a recurrence.
Herpetic geometric glossitis

Clinical manifestations Macroglossia

Herpetic geometric glossitis is a recently described Clinical manifestations
entity found in immunosuppressed patients with her-
pes simplex virus infection on the tongue [39]. Patients Macroglossia is enlargement of the tongue out of
present with extremely tender linear fissures on the proportion to the jaw size [4]. The condition may be
dorsal tongue. Often they have a striking geometric congenital or acquired. On examination the tongue
pattern with right angle radiation, but this is not appears large within the mouth. The lateral margins
consistently present (Fig. 13, Table 9). The lesions are scalloped from the constant pressure of the teeth
are found on the central tongue and notably herpetic (Fig. 14, Table 10). If a few teeth are missing, the
lesions on other mucosal surfaces are absent. tongue may expand into the available space to
produce a pseudotumor appearance. Hemorrhages
Diagnosis and treatment may be evident if the enlargement is sufficient to
interfere with talking or mastication such that tongue
This condition has been reported only in immu- biting occurs. On palpation the tongue typically has a
nocompromised hosts and is thought to be caused by hard woody induration.
chronic herpes simplex virus infection because the
glossitis responds to treatment with oral antiviral Diagnosis and treatment
therapy. Viral culture, Tzanck smear, or biopsy estab-
lishes diagnosis. With antiviral treatment herpetic Many associations exist including Down syn-
drome, amyloidosis, and hypothyroidism (Table 11).

Table 11
Causes of macroglossia
Etiology Diseases
Primary Down syndrome, or developmental
Tumors Hemangioma, lymphangioma,
neurofibroma, neurilemmoma, or
thyroglossal duct cyst
Infections Actinomycosis, tuberculosis,
histoplasmosis, or syphilis
Metabolic Hypothyroidism, acromegaly, multiple
myeloma, or amyloidosis
Fig. 14. Macroglossia. This enlarged tongue has a scallop- Other Angioedema, sarcoidosis, or
ed border. superior vena cava syndrome
132 J.A. Byrd et al. / Dermatol Clin 21 (2003) 123–134

Fig. 15. Amyloidosis. (A) Smooth tongue with macroglossia. (B) Purpura on the arm on a patient with amyloidosis,
demonstrating pinched purpura. (C) Histopathology of amyloidosis demonstrating amorphous eosinophilic fissured masses in
lamina propria (hematoxylin and eosin, original magnification  10).

Amyloidosis may present with macroglossia and protein, work-up for myeloma, and serologic test for
pinch purpura (purpura following trauma). Fig. 15 syphilis should be performed. Biopsy may be neces-
demonstrates the characteristic smooth tongue and sary for diagnosis. Treatment depends on the cause of
associated purpura seen in patients with amyloidosis. the macroglossia.
Evaluation should be tailored to elicit the cause.
Infection should be ruled out by taking fungal,
bacterial, and mycobacterial cultures. Laboratory Summary
evaluation including a complete blood count, routine
chemistry, thyroid-stimulating hormone, serum pro- Patients frequently present complaining of tongue
tein electrophoresis, urinary screen for Bence Jones abnormalities. Knowledge of normal tongue ana-
 J.A. Byrd et al. / Dermatol Clin 21 (2003) 123–134 133

tomy and architecture enable the clinician to differ- orofacial granulomatosis. Dermatol Clin 1996;14:
entiate variations of normal from abnormal con- 371 – 9.
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Orofacial manifestations of Melkersson-Rosenthal syn-
require reassurance and explanation, with little to
drome: a study of 42 patients and review of 220 cases
no treatment. Others can signify systemic disorders.
from the literature. Oral Surg Oral Med Oral Pathol
Examination of the tongue is an integral part of a 1992;74:610 – 9.
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