Angular Cheilitis

Definition

• Angular Cheilitis (also called angular stomatitis or perlèche) is an inflammatory condition primarily affecting the corners (angles) of the mouth.

• May present as acute or chronic, often recurrent if underlying factors persist.

• Common in both children and adults, especially those with poor general health or immunocompromise.

Risk Factors

• Saliva pooling at the mouth corners (excess drooling, mouth breathing, poorly fitting dentures).

• Candida overgrowth (oral thrush).

• Poor denture fit (especially in older adults).

• Systemic diseases: Crohn’s disease, coeliac disease, Sjögren’s syndrome, diabetes mellitus (due to dryness or immunosuppression).

• Nutritional deficiencies (iron, zinc, B vitamins).

• Immunosuppression (e.g. HIV, chronic steroid use).

Aetiology & Pathophysiology

• Excess saliva and local irritation lead to maceration of the skin at the angles of the mouth.

• Secondary infection can develop, most commonly:

  • Fungal: Candida albicans (most frequent overall)

  • Bacterial: Staphylococcus aureus

  • Viral: Herpes simplex virus (less common)

• Nutritional factors (e.g., low iron, zinc, vitamins B2, B6, B12) can predispose or exacerbate.

Clinical Features

1. Skin Lesions

   • Painful cracks (fissures) and sores at the corners of the mouth.

   • Redness, erythema, possible blistering or bleeding.

   • Crusting or scaling may develop in chronic cases.

2. Symptoms

   • Burning, stinging, or pain aggravated by mouth movements (talking, chewing).

   • May have associated dryness or chapping of the lips.

3. Complications

   • Chronic angular cheilitis can lead to scarring, persistent infection, or extension to adjacent skin.

Diagnosis

• Usually a clinical diagnosis based on characteristic lesions at the mouth corners.

• Swab for microbiological culture (fungal, bacterial) if the lesion is resistant to standard therapies or if the diagnosis is uncertain.

• Consider patch testing for allergic contact dermatitis in atypical presentations.

• Evaluate for nutritional deficiencies (iron, folate, B12) and dental/oral factors (denture fit, oral candidiasis).

Management

General Measures

• Lip care: Use emollients or lip balms to keep lips hydrated and prevent further cracking.

• Avoid lip-licking: Saliva evaporation worsens dryness and maceration.

• Oral hygiene: Regular dental checks; ensure dentures are well-fitting.

• Saliva pooling reduction: Barrier creams (e.g. petroleum jelly) at the mouth corners.

Targeted Treatment

1. Antifungal Treatment (suspected or confirmed Candida):

   • Topical miconazole gel or clotrimazole cream applied to the angles of the mouth 2–3 times daily.

   • Continue for at least 2 weeks or until complete resolution.

   • If intra-oral candidiasis is present, treat accordingly (e.g. nystatin oral suspension, miconazole oral gel).

2. Antibacterial Treatment (suspected or confirmed Staphylococcus aureus):

   • Topical antibiotics such as mupirocin or fusidic acid 2–3 times daily.

   • Consider oral antibiotics if severe or refractory infection.

3. Mild Topical Steroids

   • Low potency (e.g. hydrocortisone 1%) if inflammation is prominent and infection is ruled out or concurrently addressed.

   • Short-term use to reduce inflammation; avoid prolonged steroid monotherapy if infection is a concern.

4. Nutritional Supplementation

   • Iron, zinc, or B vitamins if deficiency is suspected or confirmed.

   • Encourage a balanced diet or refer to a dietitian if indicated.

Prevention

• Maintain good oral hygiene and denture care (clean dentures daily; adjust for proper fit).

• Use of barrier agents (lip balm, petroleum jelly) if there is a tendency for saliva pooling.

• Correct underlying causes:

  • Manage oral thrush promptly.

  • Identify and treat nutritional deficiencies.

  • Monitor for dermatological or systemic conditions (e.g. Crohn’s, Sjögren’s).

Key Points

1. Multifactorial Aetiology: Usually a combination of moisture, friction, and infectious agents (often Candida).

2. Common in Older Adults: Denture-related issues and xerostomia (dry mouth) are often implicated.

3. Simple Measures: Lip hydration, barrier creams, improved oral hygiene frequently help mild cases.

4. Topical Therapy: Select based on most likely pathogen—antifungal (for Candida), antibiotic (for Staph.), mild steroid if primarily inflammatory.

5. Investigate Persistence: Chronic or recurrent angular cheilitis warrants further evaluation (nutritional, immunological, mechanical factors).