Peer Reviewed

Photo Essay

An Atlas of Lingual Lesions, Part 1

Alexander K. C. Leung, MD
Clinical Professor of Pediatrics, University of Calgary; Pediatric Consultant, Alberta Children’s Hospital, Calgary, Alberta, Canada

Benjamin Barankin, MD
Dermatologist, Medical Director, and Founder, Toronto Dermatology Centre, Toronto, Ontario, Canada

Kin Fon Leong, MD
Pediatric Dermatologist, Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia

Helen Tam-Tham, PhD
Medical Student, University of Calgary, Calgary, Alberta, Canada

Leung AKC, Barankin B, Leong KF, Tam-Tham H. An atlas of lingual lesions, part 1. Consultant. 2019;59(5):146-148, 151.

EDITOR’S NOTE: This article is part 1 of a 5-part series of Photo Essays describing and differentiating conditions affecting the tongue and related structures in the oral cavity. Parts 2, 3, 4, and 5 are published in subsequent issues of Consultant.


Strawberry Tongue

A strawberry tongue is most commonly caused by group A β-hemolytic streptococcal pharyngitis, which leads to hypertrophy of the papillae.1,2 The prominent papillae are initially covered by a white coating, giving the appearance of a white strawberry tongue (Figure 1).3 The white coating is usually lost in 1 to 2 days, giving rise to a red strawberry tongue (Figure 2).3 Other features of group A β-hemolytic streptococcal pharyngitis include fever, beefy red pharynx, enlarged and erythematous tonsils with or without exudates, enlarged tender anterior cervical lymph nodes, and sometimes, palatal petechiae, and a scarlatiniform rash.1


Fig 1
Figure 1.

Fig 2
Figure 2.

Group A β-hemolytic streptococcal pharyngitis may lead to local suppurative complications such as peritonsillar abscess, suppurative cervical lymphadenitis, cellulitis, and retropharyngeal abscess.1 Rarely, group A β-hemolytic streptococcal pharyngitis may result in bacteremia, necrotizing fasciitis, and streptococcal toxic shock-like syndrome.2 Nonsuppurative complications can include acute glomerulonephritis, rheumatic fever, reactive arthritis-synovitis, and pediatric autoimmune neuropsychiatric disorder.1

Strawberry tongue is a notable feature of Kawasaki disease.4 Kawasaki disease is an acute vasculitis, a systemic disease that mostly involves coronary arteries and typically occurs in children younger than 5 years of age.4 The diagnosis of classic or typical Kawasaki disease is based on clinical criteria established by the American Heart Association.5 These criteria include fever for at least 5 days (the first calendar day of the established fever is illness day 1) and 4 or more of the 5 primary clinical features without plausible alternative explanations: oral mucosal changes (strawberry tongue, erythematous, fissured cracked lips, diffuse erythema of the oral pharynx); bilateral bulbar conjunctival injection without exudate; polymorphous rash (diffuse maculopapular, urticarial, erythroderma, erythema multiforme-like, not vesicular or bullous); changes in the extremities (erythema and indurated edema of the hands and feet, sharp demarcation at the ankles and wrists, periungual desquamation); and cervical lymphadenopathy (unilateral, >1.5 cm in diameter, nonfluctuant).5 In the presence of 4 or more major features, mainly when redness and swelling of the hands and feet are present, the diagnosis can be made with only 4 days of fever.5 Patients who have a fever for 5 or more days and only 3 major clinical features can also receive a classic Kawasaki disease diagnosis when coronary artery disease is detected by 2-dimensional echocardiography or coronary angiography.5

Rarely, strawberry tongue can be caused by yellow fever and Yersinia pseudotuberculosis.3


  1. Leung AKC, Kellner JD. Group A β-hemolytic streptococcal pharyngitis in children. Adv Ther. 2004;21(5):277-287.
  2. Leung TNH, Hon KL, Leung AKC. Group A Streptococcus disease in Hong Kong children: an overview. Hong Kong Med J. 2018;24(6):593-601.
  3. Adya KA, Inamadar AC, Palit A. The strawberry tongue: what, how and where? Indian J Dermatol Venereol Leprol. 2018;84(4):500-505.
  4. Yuan K, Park JK, Qubti MA, Haque UJ. Recurrent Kawasaki disease with strawberry tongue and skin desquamation in a young adult. J Clin Rheumatol. 2012;18(2):96-98.
  5. McCrindle BW, Rowley AH, Newburger JW, et al; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Council on Epidemiology and Prevention. Diagnosis, treatment, and long-term management of Kawasaki disease: a scientific statement for health professionals from the American Heart Association. Circulation. 2017;135(17):e927-e999.

NEXT: Fissured Tongue

Fissured Tongue

Fissured tongue, also known as scrotal tongue, plicated tongue, lingua plicata, lingua fissurata, and groove tongue, is characterized by fissures and grooves that vary in depth along the dorsal and lateral aspects of the tongue (Figures 1 and 2).1,2 A central longitudinal fissure or groove is often noted (Figure 2).3 Fissured tongue is seen in 5% to 11% of the general population.4 The condition is not common before 10 years of age, and the prevalence increases with age.3 There is a predominance in the male population.3

fig 1
Figure 1.

fig 2
Figure 2.

The exact etiology of fissured tongue is not known, and the condition is idiopathic in most cases. A polygenic or autosomal dominant mode of inheritance has been postulated due to clustering of the condition in families.3 Smoking is a known risk factor.3 Fissured tongue has been associated with geographic tongue, scrotal glans penis, pachyonychia congenita, psoriasis, Melkersson-Rosenthal syndrome, Down syndrome, Cowden syndrome, Moebius syndrome, Sjögren syndrome, Touraine Solente Gole syndrome, acromegaly, diabetes mellitus, pernicious anemia, and hypovitaminosis A.1,5-11

The diagnosis of fissured tongue is mainly clinical. The condition is usually asymptomatic and is often an incidental finding. The tongue can be painful if it is inflamed. The fissures may collect food particles and debris, resulting in irritation, inflammation, and halitosis. Therefore, appropriate oral hygiene is essential. Gentle brushing of the tongue with a soft-bristled toothbrush deep into the fissures to remove food particles and debris after meals and before sleeping is recommended.2,3 



  1. Järvinen J, Mikkonen JJW, Kullaa AM. Fissured tongue: a sign of tongue edema? Med Hypotheses. 2014;82(6):709-712.
  2. Mangold AR, Torgerson RR, Rogers RS III. Diseases of the tongue. Clin Dermatol. 2016;34(4):458-469.
  3. Feil ND, Filippi A. Frequency of fissured tongue (lingua plicata) as a function of age. Swiss Dent J. 2016;126(10):886-897.
  4. Rogers RS III, Bruce AJ. The tongue in clinical diagnosis. J Eur Acad Dermatol Venereol. 2004;18(3):254-259.
  5. Al-Maweri S-A, Tarakji B, Al-Sufyani GA, Al-Shamiri HM, Gazal G. Lip and oral lesions in children with Down syndrome. A controlled study. J Clin Exp Dent. 2015;7(2):e284-e288.
  6. Athappan G, Unnikrishnan A, Chengat V, et al. Touraine Solente Gole syndrome: the disease and associated tongue fissuring. Rheumatol Int. 2009;29(9):1091-1093.
  7. Cancian M, Giovannini S, Angelini A, et al. Melkersson-Rosenthal syndrome: a case report of a rare disease with overlapping features. Allergy Asthma Clin Immunol. 2019;15:1. doi:10.1186/s13223-018-0316-z.
  8. De Serpa Pinto MVX, De Magalhães MHCG, Nunes FD. Moebius syndrome with oral involvement. Int J Paediatr Dent. 2002;12(6):446-449.
  9. Fisher BK, Linzon CD. Scrotal glans penis (glans penis plicatum) associated with scrotal tongue (lingua plicata). Int J Dermatol. 1997;36(10):762-763.
  10. Masmoudi A, Chermi ZM, Marrekchi S, et al. Cowden syndrome. J Dermatol Case Rep. 2011;5(1):8-13.
  11. Picciani BLS, Teixeira-Souza T, Pessôa TM, et al. Fissured tongue in patients with psoriasis. J Am Acad Dermatol. 2018;78(2):413-414.

NEXT: Hairy Tongue

Hairy Tongue

Hairy tongue, also known as lingua villosa or furred tongue, results from the accumulation of excess keratin on the filiform papillae of the dorsal tongue, leading to elongation and hypertrophy of filiform papillae that resemble hair (Figure).1 The prevalence is estimated to be 3% to 4% of the adult population and increases with age.2 Rarely, the condition has been reported in children.3,4 The male to female ratio is approximately 3 to 1.5,6

hairy tongue

Clinically, a hairy tongue is characterized by hair-like projections on the dorsal surface of the tongue with typical carpet-like appearance that can be scraped off.5,6 Typically, the condition does not occur on the sides of the tongue, tip of the tongue, or posterior to the circumvallate papillae/sulcus terminalis.5 The color of the tongue varies from yellow, tan, brown, green, blue, or, more commonly black (lingua villosa nigra).1,2,5,6 The discoloration results from chromogenic bacteria or yeast trapped between the hyperkeratotic papillae.2 Most patients are asymptomatic, although some patients may have a stale/metallic taste, nausea, gagging, tickling of the tongue, or halitosis.1-3 The condition may cause cosmetic concerns to the patient.5

A hairy tongue occurs most commonly in older adults, smokers, mouth-breathers, and those with poor oral hygiene.1,2,6 Other predisposing factors include excessive coffee or black tea consumption, alcoholism, xerostomia, medications (eg, penicillin, erythromycin, tetracycline, linezolid, bismuth, ranitidine, lansoprazole, methyldopa, olanzapine, lorazepam, lithium), prolonged use of oxidizing mouthwashes, and, less commonly, substance abuse, HIV infection, graft-versus-host disease, trigeminal neuralgia, and internal malignancies.3,5,6

The condition is benign. Treatment of hairy tongue is mainly symptomatic and consists of maintaining regular appropriate oral hygiene and gentle debridement with a soft-bristled toothbrush or tongue scraper.2 Predisposing factors should be avoided if possible.



  1. Reamy BV, Derby R, Bunt CW. Common tongue conditions in primary care. Am Fam Physician. 2010;81(5):627-634.
  2. Rogers RS III, Bruce AJ. The tongue in clinical diagnosis. J Eur Acad Dermatol Venereol. 2004;18(3):254-259.
  3. Akcaboy M, Sahin S, Zorlu P, Şenel S. Ranitidine-induced black tongue: a case report. Pediatr Dermatol. 2017;34(6):e334-e336.
  4. Popik E, Barroso F, Pombeiro J, Carvalho C, Almeida A. Hairy tongue in a 1-month-old infant. Arch Dis Child. 2019;104(2):158.
  5. Gurvits GE, Tan A. Black hairy tongue syndrome. World J Gastroenterol. 2014;20(31):10845-10850.
  6. Mangold AR, Torgerson RR, Rogers RS III. Diseases of the tongue. Clin Dermatol. 2016;34(4):458-469.