Angular cheilitis

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 B ₁₂ deficiency. An eczematous dermatitis of the lower face suggests a staphylococcal infection (infectious eczematoid dermatitis). A history of allergic contact dermatitis may suggest an allergy.

Unilateral lesions are usually short lived and induced by mechanical factors. This has also been reported to be a manifestation of plasma cell cheilitis. 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. Highly active antiretroviral therapy (HAART) may decrease this incidence. Both Candida albicans and Staphylococcus aureus can colonize the fissures. Anemia, nutritional deficiencies, Down syndrome, acrodermatitis enteropathica, pemphigus vulgaris, diabetes mellitus, orofacial granulomatosis, and Crohn 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 imidazole creams after meals and at bedtime may treat candidiasis, whereas 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.