Angular Cheilitis

• Gregory M. Haidemenos, M.D.

 Basic Information

Definition

Angular cheilitis refers to inflammation of one, or both, of the corners of the mouth resulting in erythema, fissuring, and exudate of the mouth angle (Fig. E1). Most commonly, it represents an infectious etiology, as an opportunistic fungal or bacterial pathogen, and leads to a spectrum of varying severities.

Synonyms

1. Angular cheilosis

2. Rhagades

3. Commissural cheilitis

4. Perleche

5. Angular stomatitis

ICD 10-CM CODE(S)
K13.0	Diseases of lips
B37.83	Candidal cheilitis

Epidemiology & Demographics

Incidence

Unknown

Peak Incidence

Advanced age

Prevalence

Suspected of causing 0.5% to 5% of lip infections in adults

Predominant Sex and Age

This form of lip inflammation has a predilection for the elderly, seen with denture use as an example.

Genetics

No identified correlation

Risk Factors

These include dry mouth, nutritional deficiencies (B vitamins, iron), immunosuppression, or chronic irritation as with lip licking, drooling, oral hardware, or dentures.

Physical Findings & Clinical Presentation

1. •

   The majority of cases of this lip condition involve both sides of the mouth, which initially involves erythema and swelling (Fig. E2). Over time, the erythema and subsequent linear fissures, or rhagades, may become cracked or ulcerated. Skin thickening is common during the progression of inflammation. It is important to note that this progression may involve strictly the mucosa of the lips or may propagate to the facial dermis, crossing the vermillion border.

Etiology

1. •

   Microorganisms commonly represent underlying infectious causes. These include Candida species, Staphylococcal aureus, beta-hemolytic Streptococcus species, or polymicrobial findings. Another common cause of this condition includes direct irritation of saliva on the corners of the mouth with overclosure of the lower jaw, as evident in edentulous individuals and those who wear dentures. Nearly any condition that leads to chronic irritation or moisture settling in the corners of the mouth, including lip licking, drooling, or habits of oral fixation, may lead to this state. Nutritional deficiencies, specifically of iron, B vitamins, and zinc, are also associated with angular cheilitis. Varying levels of immunosuppression, as seen in diabetes mellitus, HIV, and so on, predispose to subacute infection as well. Patients on medications leading to xerostomia or hypersalivation can develop bilateral involvement.

Diagnosis

Differential Diagnosis

1. •

   Oral candidiasis or oral-associated angular cheilitis; S. aureus infection or impetigo; contact dermatitis; angular herpes simplex

Work-Up

1. •

   Primarily clinical in nature, taking into consideration full details of the patient’s medical history and medications

Laboratory Tests

1. •

   If applicable, bacterial and fungal cultures may be beneficial to detect probable infectious component with routine lab testing, including CBC, HIV, BMP, iron, folate, and vitamin B₁₂, to be performed as well.

Imaging Studies

1. •

   None needed

Treatment

The hallmark of treatment used in this condition revolves around proper identification and understanding of the etiology of the inflammation. With the highest prevalence of this condition seen in those with dentures, proper oral fit and dental hygiene are of the utmost importance.

Certainly, good oral hygiene also includes smoking and tobacco use cessation. Topical antifungal use is at the cornerstone of treatment (details follow). Proper identification may include the presence of S. aureus, Streptococcus species, and other pathogens, which will need focused treatment. Treatment-refractory cheilitis may require additional workup to identify possible systemic etiology.

Nonpharmacologic Therapy

1. •

   Dental hygiene, specifically, with a focus on proper cleaning of dentures, plays a pivotal role in prevention. Alcohol or bleach-based solutions are commonly available OTC. If significant lag is noted in the corners of the mouth, surgery and collagen injections have been successful. Petrolatum jelly has been used for preventive measures as well.

Acute General Rx

1. •

   With the underlying pathology involving inflammation, topical corticosteroid creams are commonly used. If S. aureus has been implicated, topical mupirocin or fusidic acid has a role. Clotrimazole or ketoconazole can be used for combating Candida albicans, implicated in >50% of cases.

Chronic Rx

1. •

   Pending laboratory workup and identification of a nutritional deficiency, iron, B vitamins, or folate supplementation will likely lead to reduction. Proper alignment of dentures, involving possible surgical repair and fitment, may be needed.

Disposition

1. •

   Outpatient workup and assessment

Referral

1. •

   Dermatology assessment may be needed in refractory cases of angular cheilitis.

Pearls & Considerations

Comments

Identification of etiology is of utmost importance for further workup.

Prevention

See previously.