Ask Dr James: Why do my lips keep swelling up?

In his regular column, Dr James Le Fanu answers readers’ questions. This week: a reader with unexplained swollen lips

Every few days my top lip swells up like a balloon, sometimes it is the lower one or both together. Besides the embarrassing appearance it is really quite painful and makes eating and talking difficult. I have been advised this is an allergic reaction and prescribed antihistamines but they don’t seem to make much difference. Nobody seems to have a clear idea what the explanation might be or how to prevent it.
This is a fairly common if curious complaint that can involve any part of the body – hands, trunk, limbs – but most strikingly when affecting the face and lips. It is known as angioedema, a (typically obscure) technical term to describe its two salient features: swelling (oedema) due to the outpouring of fluid from the blood vessels (angio) into the surrounding tissues. The swelling may last from a few hours to several days and usually resolves spontaneously but warrants treatment to alleviate the discomfort and minimise the adverse consequences for the two main functions of the lips – being indispensable for eating and drinking (preventing food and liquids from spilling out) and also, when talking, ensuring the clear enunciation of the consonants of speech. There is little difficulty, given the characteristic appearance, in making the diagnosis but ascertaining its probable cause is not necessarily straightforward.
The most readily identifiable of those causes is an acute allergic reaction to food, the leading culprits predictably being nuts (of course), dairy products (milk and eggs), shellfish and chilli peppers. Perplexingly, for those afflicted the first attack comes seemingly out of the blue. “In my case it was fish which, living near the sea, I had eaten happily all my life,” writes one woman. “Then suddenly a few hours after my evening meal my lips would swell up alarmingly.” The link, as here, is usually easily made, allowing for the prevention of further episodes by avoiding the food in question.
The immediate discomfort and swelling can be mitigated by applying a cool compress (or ice cubes) and, as the allergic reaction is mediated by the chemical histamine, taking an antihistamine such as fexofenadine or cetirizine – though this may have to be taken at a considerably higher dosage than is customary. In particularly severe, persistent attacks oral steroids (prednisolone) may be required.
Drugs can cause angioedema in two ways. This may, as with foods, be an acute allergic response to, for example, penicillin or aspirin. The swelling comes on rapidly within a couple of hours, so again the link is readily made. More problematically, the commonly prescribed blood pressure-lowering ACE inhibitors (captopril, lisinopril) can cause a more severe form, the connection being overlooked as it may not manifest for months after initiating treatment.
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