Angular cheilitis

Published on 18/03/2015 by admin

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Last modified 22/04/2025

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Angular cheilitis

Jennifer K. Chen and Janellen Smith

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Angular cheilitis is a chronic reactive inflammatory condition of the oral commissures characterized by atrophy, fissures, crusting, erythema, and scaling. Etiology is often multifactorial, and causes may be mechanical (intertrigo), infectious, nutritional, hormonal, or inflammatory. Angular cheilitis may be a sign of systemic disease such as diabetes mellitus or HIV infection.

Management strategy

Successful therapy is based on identifying and correcting any underlying condition(s). The presence of dentures, palatal erythema, and/or edema may suggest candidiasis and denture stomatitis. A pale, depapillated, atrophic tongue suggests iron deficiency. A tender depapillated tongue suggests folate or vitamin B12 deficiency. An eczematous dermatitis of the lower face suggests a staphylococcal infection (infectious eczematoid dermatitis). History of allergic contact dermatitis may suggest an allergy.

Unilateral lesions are usually short lived and induced by mechanical factors. Bilateral lesions tend to be chronic and caused by infection or nutritional deficiency, and are more likely to be associated with an underlying disease process.

Maceration of the commissural epithelium and adjacent skin is a common, non-infectious cause of mechanical angular cheilitis. Trauma from dental flossing, habitual lip-licking, and excessive salivation all contribute. Periods of oral hydration and then dryness disrupt epithelial integrity, causing fissuring of the commissures. This provides an ideal environment for low-grade candidiasis and infectious eczematoid dermatitis. Other mechanical factors are ill-fitting dentures, loss of vertical dimension of the jaws, sagging skin folds, xerostomia, and perioral dermatitis.

Infectious and systemic causes must be investigated. Angular cheilitis is frequently present in patients with HIV disease, where 10% may have localized candidiasis. Both Candida albicans and Staphylococcus aureus can colonize the fissures. Anemia, nutritional deficiencies, acrodermatitis enteropathica, diabetes mellitus, and Crohn’s disease may be present.

Recurrence of angular cheilitis may be prevented by eliminating offending organisms from their reservoirs. Denture stomatitis, candidiasis, and nasal colonization by staphylococci should be investigated. Topical imadazole creams after meals and at bedtime may treat candidiasis, while topical mupirocin is valuable in treating staphylococcal colonization. Dentures should be removed from the mouth nightly and cleansed well before reinsertion in the morning. New dentures may restore facial contours, increasing the vertical dimension of the jaws and face. Injection of fillers into the commissures may alleviate causative mechanical factors.

Specific investigations

First-line therapies

image Topical miconazole, ketoconazole, or nystatin cream two or three times daily for 2 to 3 weeks D
image Topical polymyxin B or mupirocin ointments D
image Remove dentures nightly and cleanse overnight with chlorhexidine 2% solution or sodium hypochlorite 0.02% solution. Rinse and air-dry prior to reinsertion. Please note that chlorhexidine and nystatin inactivate each other and therefore should not be used together D

Third-line therapies

image Filler injections E
image Prosthodontic evaluation and treatment E
image Chewing gum with xylitol or chlorhexidine acetate and xylitol B
image Gentian violet 0.5% solution twice daily E

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Angular cheilitis

Jennifer K. Chen and Janellen Smith

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Angular cheilitis is a chronic reactive inflammatory condition of the oral commissures characterized by atrophy, fissures, crusting, erythema, and scaling. Etiology is often multifactorial, and causes may be mechanical (intertrigo), infectious, nutritional, hormonal, or inflammatory. Angular cheilitis may be a sign of systemic disease such as diabetes mellitus or HIV infection.

Management strategy

Successful therapy is based on identifying and correcting any underlying condition(s). The presence of dentures, palatal erythema, and/or edema may suggest candidiasis and denture stomatitis. A pale, depapillated, atrophic tongue suggests iron deficiency. A tender depapillated tongue suggests folate or vitamin B12 deficiency. An eczematous dermatitis of the lower face suggests a staphylococcal infection (infectious eczematoid dermatitis). History of allergic contact dermatitis may suggest an allergy.

Unilateral lesions are usually short lived and induced by mechanical factors. Bilateral lesions tend to be chronic and caused by infection or nutritional deficiency, and are more likely to be associated with an underlying disease process.

Maceration of the commissural epithelium and adjacent skin is a common, non-infectious cause of mechanical angular cheilitis. Trauma from dental flossing, habitual lip-licking, and excessive salivation all contribute. Periods of oral hydration and then dryness disrupt epithelial integrity, causing fissuring of the commissures. This provides an ideal environment for low-grade candidiasis and infectious eczematoid dermatitis. Other mechanical factors are ill-fitting dentures, loss of vertical dimension of the jaws, sagging skin folds, xerostomia, and perioral dermatitis.

Infectious and systemic causes must be investigated. Angular cheilitis is frequently present in patients with HIV disease, where 10% may have localized candidiasis. Both Candida albicans and Staphylococcus aureus can colonize the fissures. Anemia, nutritional deficiencies, acrodermatitis enteropathica, diabetes mellitus, and Crohn’s disease may be present.

Recurrence of angular cheilitis may be prevented by eliminating offending organisms from their reservoirs. Denture stomatitis, candidiasis, and nasal colonization by staphylococci should be investigated. Topical imadazole creams after meals and at bedtime may treat candidiasis, while topical mupirocin is valuable in treating staphylococcal colonization. Dentures should be removed from the mouth nightly and cleansed well before reinsertion in the morning. New dentures may restore facial contours, increasing the vertical dimension of the jaws and face. Injection of fillers into the commissures may alleviate causative mechanical factors.

Specific investigations

image Culture for candidiasis

image Culture for bacteria

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