The Clinical Picture

Black hairy tongue cured concurrently with respiratory infection

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A 54-year-old female smoker was admitted to the hospital for fever and respiratory infection. On the day of admission, she reported lesions of the oral mucosa for the past several months. She denied taking any medications recently.

Black hairy tongue
Figure 1. At presentation, lesions were spread across the dorsum of the tongue.

Physical examination showed brownish papillary lesions spread across the dorsum of the tongue; the lesions were a darker shade proximally (Figure 1), leading to the diagnosis of black hairy tongue. Hygienic measures were recommended, with other treatment options to be considered later, if necessary. Of note, during her 1-week hospital stay, she was treated with levofloxacin for the respiratory infection, and she did not smoke during this period. One week after her admission, the lesions had disappeared (Figure 2).


The condition had resolved 1 week later.
Figure 2. The condition had resolved 1 week later.

Black hairy tongue (lingua villosa nigra) is a rare but benign condition caused by defective desquamation and reactive hypertrophy of the filiform papillae of the tongue. Causes that have been proposed include medications, hyposalivation, poor oral hygiene, oxidizing mouthwashes (eg, hydrogen peroxide), alcohol, smoking, and infection.1

The differential diagnosis includes acanthosis nigricans, oral hairy leukoplakia, oral candidiasis, pigmented fungiform papillae, Addison disease, and black staining over a normal tongue from bismuth or food colorings.


Visual inspection and a detailed history are often sufficient for diagnosis. The optimal treatment is unclear, but the condition can improve with hygienic measures alone, topical or oral retinoids,2 topical triamcinolone acetonide, salicylic acid, vitamin B complex, or antifungals. There are isolated cases in the literature in which improvement occurred with antibiotics, but their role is unclear.1 Rarely, surgical excision of the filliform papilla in black hairy tongue has been done for symptomatic relief and cosmetic purposes.3

While our patient presented with typical features of black hairy tongue, which resolved with hygienic measures and smoking cessation, we could not completely rule out the contribution of antibiotics given for the respiratory infection. It is important to keep this disease in mind to avoid unnecessary tests and to apply the most appropriate treatment according to the patient’s symptoms.

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