Angina Bullosa Hemorrhagica

Updated: Dec 15, 2017
  • Author: Kara Melissa Torres Culala, MD; Chief Editor: Dirk M Elston, MD  more...
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Angina bullosa hemorrhagica (ABH) is the term used to describe acute, benign, and generally subepithelial oral mucosal blisters filled with blood that are not attributable to a systemic disorder or hemostatic defect. [1, 2, 3, 4]

This condition was first described in 1933 as traumatic oral hemophlyctenosis. Badham first used the currently accepted term angina bullosa hemorrhagica in 1967.

The lesions may be confused with other more serious disorders (eg, mucous membrane pemphigoid, epidermolysis bullosa, linear IgA, dermatitis herpetiformis); however, the isolated nature, rapid healing, and rare recurrence of angina bullosa hemorrhagica blisters generally are sufficient findings to rule out the previously mentioned conditions.

The lesions of angina bullosa hemorrhagica may be indistinguishable from blood blisters related to thrombocytopenia; however, blood tests and the absence of areas of ecchymosis, epistaxis, or gingival bleeding are helpful signs to rule it out.

Some authors suggest mild trauma as the causative agent in angina bullosa hemorrhagica to break the epithelial–connective-tissue junction, causing bleeding of superficial capillaries and resulting in the formation of a subepithelial hemorrhagic bullae.

Also see the Medscape articles Bullous Pemphigoid, Epidermolysis Bullosa, Linear IgA Dermatosis, and Dermatitis Herpetiformis.



A genetic predisposition of loose adhesion between the epithelium and corium of the mucosa or a weak anchorage of the mucosal vessels may result in subepithelial hemorrhage. [5]

Angina bullosa hemorrhagica (ABH) may also represent an acute or chronic injury to soft tissue. It is an example of an oral mucosal traumatic lesion. [6, 7] Angina bullosa hemorrhagica most commonly occurs in the soft palate where the covering squamous epithelium of the nonkeratinized type is thin and friable. [8] The break in the epithelial-connective–tissue junction causes bleeding of the superficial capillaries, resulting in the formation of the subepithelial hemorrhagic bullae. [8]

Angina bullosa hemorrhagica may also be a rare and underestimated adverse effect of inhalational corticosteroid therapy. The resulting collagen synthesis modifications lead to mucosal atrophy and a decrease in submucosal elastic fibers, especially in the elderly population over the long term (>5 y). Long-term use of such inhalers may induce capillary breakdown. [8, 9] Similarly, vascular fragility has also been implicated, in view of the association of angina bullosa hemorrhagica with diabetes mellitus. [5]



The described cases of angina bullosa hemorrhagica (ABH) had spontaneous onset or were related to minor trauma of ingestion of hot drinks [10] ; hard, rough, and crispy foods [11, 8] ; restorative dentistry [12] ; or periodontal therapy. [13]

Other potential causes of angina bullosa hemorrhagica mentioned in the literature are dental injections of anesthetics [11, 14] ; steroid inhalers [15, 14] ; endoscopy [10] ; trauma from the sharp edges of adjacent teeth, metal crowns, and prosthetic use [5, 16] ; tobacco consumption [16] ; anticoagulant intake [17] ; and coughing, sneezing, and shouting. [18, 8]

A report of 16 cases affecting the soft palate described hypertension as the most frequent underlying systemic condition (6 of 16 subjects); however, its relationship remains speculative, as hypertension is common in adults. [8] Other reported associated systemic factors were diabetes mellitus, chronic kidney injury on hemodialysis, asthma, rheumatoid arthritis, gastrointestinal disturbances, hyperuricemia, and systemic lupus erythematosus. [18, 17, 13, 5, 19, 20]

In general, angina bullosa hemorrhagica is not attributable to blood dyscrasia, vesiculobullous disorders, or systemic diseases. A causative factor is not identified in approximately 47% of patients with angina bullosa hemorrhagica. [18]




No sex predilection is reported for angina bullosa hemorrhagica (ABH).


Angina bullosa hemorrhagica (ABH) predominantly affects middle-aged or elderly people. The median age at presentation is 54 years, with 60% of the patients in the range of 45-70 years. Lesions have not been documented in children younger than 10 years.



The prognosis for angina bullosa hemorrhagica (ABH) is good. Recurrences have been reported to occur once or twice a year in 30% of the affected population at the same or different site, with no specific precipitating factor (eg, trauma) or seasonal predilection. [21, 19]

ABH is a benign condition; however, some authors have reported acute upper airway obstruction associated with rapidly enlarging bulla of the posterior pharynx and epiglottic region. [18] Rarely, tracheal intubation and surgical tracheostomy are required in such patients.