Black Hairy Tongue in Adults

Black hairy tongue is a benign condition in which the filiform papillae on the back of the tongue lengthen and become stained, producing a black, brown or yellow furry appearance. Papillae fail to shed normally.

• Risk factors are smoking, poor oral hygiene, heavy tea or coffee intake, broad spectrum antibiotics, chlorhexidine, bismuth, linezolid and radiotherapy.
• Dehydration, xerostomia, soft diet and diabetes contribute.
• It is more common in older adults and men.

Dark, furry coating on the posterior two thirds of the tongue, often painless, with bad breath, altered taste and a gagging sensation.

• Papillae may reach 1 cm in length.
• Differential diagnosis: oral candidiasis, hairy leukoplakia (HIV), oral melanoma, lingual pigmentation from drugs, geographic tongue, tongue coating from poor hygiene, acanthosis nigricans.
• Complications: halitosis, gagging, secondary candidiasis, social embarrassment.

Clinical examination.

• Review of drugs, smoking and diet.
• KOH or swab for candida if there are white patches or soreness.
• Biopsy and HIV test if hairy leukoplakia on the lateral tongue or a pigmented lesion is suspected.

Remove the cause and restore normal desquamation.

• Supportive: brush or scrape the tongue twice daily with a soft toothbrush or scraper, stop smoking, reduce tea and coffee, stop or replace the causative drug where possible, drink plenty of water, add fibrous fruit and vegetables to the diet.
• Pharmacological: sodium bicarbonate 5 percent mouthwash twice daily; nystatin suspension 100,000 units/mL, 4 to 6 mL four times daily for 7 to 14 days, or fluconazole 100 mg daily for 7 days, when candida is present; topical tretinoin 0.025 percent applied to the tongue for resistant cases under specialist care.
• Procedures: clipping or electrosurgical removal of very long papillae in refractory disease.
• Special groups: HIV, treat candidiasis and optimise antiretroviral therapy; pregnancy, mechanical cleaning only; children, rare, review drugs.
• Red flags: lateral tongue white patch that does not wipe off, pigmented ulcer or nodule, bleeding, induration, weight loss.
• Follow-up: review at 4 weeks; refer if the coating does not clear after the cause is removed.