What does a pale tongue mean?

These get confused, but they have different causes.

• A white tongue has a white layer on top: debris, bacteria or yeast. You can usually see the pink tongue underneath when you scrape it. That is covered in our guide to why a tongue turns white.
• A pale tongue is light in color itself. There is no coating to remove; the tissue just looks less pink than usual. Often the gums, inner lips and the inside of the lower eyelids look pale too.

The MSD Manual explains that anemia can make the lining of the mouth pale instead of its normal healthy reddish pink. Because the tongue has a rich blood supply, it is one of the places where low hemoglobin can show.

Iron deficiency anemia

The most common type of anemia. The NHS lists tiredness, shortness of breath, palpitations, paler than usual skin and headaches as the main symptoms, with a sore tongue, strange-tasting food, cracks at the corners of the mouth, spoon-shaped nails and cravings for ice or other non-food items as less common ones. Heavy periods, pregnancy and bleeding in the stomach or bowel are common causes, according to the NHS.

Vitamin B12 deficiency and pernicious anemia

Pernicious anemia is an autoimmune condition that stops the body absorbing B12. The MSD Manual lists it as a cause of a pale, smooth tongue. B12 or folate deficiency can also make the tongue red and sore instead; the NHS lists "a sore or red tongue, sometimes with mouth ulcers." Either pattern is a reason for a blood test. B12 deficiency can also cause pins and needles, balance problems and memory changes.

Other nutritional causes

The Merck Manual notes that people with riboflavin (B2) deficiency often look pale, with painful cracks at the corners of the mouth and a tongue that may turn magenta.

Shock or acute blood loss

Sudden paleness of the skin, lips and tongue with cool, clammy skin, a fast weak pulse, shallow breathing, confusion or fainting can be shock. MedlinePlus says to call 911 any time a person has symptoms of shock.

Other reported associations

Cleveland Clinic mentions a 2017 study in which many people with eczema had gray or pale tongues. The evidence here is limited, and eczema alone is not a reason to expect a pale tongue.

1. Look in natural daylight, not under warm indoor lighting, which can wash out pink tones.
2. Compare the tongue with your gums and the inside of your lower eyelid. If all three look pale, that is more meaningful than the tongue alone.
3. Scrape or brush the top of the tongue. If the color underneath is normal pink, the "paleness" was a light coating.
4. Check for a smooth, shiny surface. Loss of the normal rough texture, along with paleness, fits with anemia.

Normal tongue color varies between people. See our page on normal tongue color for the healthy range.

A full blood count shows whether you are anemic and what type of anemia it is. Depending on the result, a doctor may check iron stores, B12 and folate, and look for a cause such as heavy periods, diet or bleeding in the gut. The NHS notes that iron deficiency from bleeding in the stomach or bowel can be caused by anti-inflammatory painkillers like ibuprofen and aspirin, stomach ulcers or, less commonly, bowel or stomach cancer, which is why finding the cause matters as much as treating the number.

Treatment follows the cause: iron tablets for iron deficiency, B12 tablets or injections for B12 deficiency, and treatment of any underlying blood loss.

• Get tested before you self-treat. Iron tablets do not fix B12 deficiency, and iron deficiency itself can be the first sign of blood loss that a doctor needs to find. A blood test sorts out which you have.
• Eat iron- and B12-rich foods such as meat, fish, eggs, dairy, beans, lentils, dark leafy greens and fortified cereals while you wait for an appointment. If you are vegan, the NHS advises B12 supplements or fortified foods.
• Keep the tongue clean and comfortable. If it is sore, use a soft toothbrush and skip spicy or acidic foods. Tongue cleaning does not change paleness caused by anemia.