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Angular Cheilitis / Angular Stomatitis
How is it Diagnosed?

This is usually a clinical diagnosis, made by clinical
examination alone.

Angular cheilitis accompanied by alopecia, diarrhoea and
non-specific
oral ulcerations, most commonly of the tongue
and
buccal mucosa, may suggest zinc deficiency.


What are the causes of Angular Cheilitis?

Predisposing Factors

AC
is predisposed by what are known as the '3Ds'.

Denture-wearing and disorders that predispose to
Candidiasis:

  • dry mouth
  • tobacco smoking.

Deficiency states such as:

  • iron deficiency
  • hypovitaminoses (especially B)
  • mal-absorption states (e.g. Crohn's disease)
  • possibly zinc deficiency (rarely)
  • defects in immunity such as in Down syndrome, HIV
    infection, diabetes, cancer and others.

Disorders where the lips are enlarged, such as oro-facial
granulomatosis
, Crohn's disease and Down syndrome.


A number of factors (
infective, mechanical, nutritional or
immunological) may be implicated alone or in
combination.  
AC is most often chronic, seen in the elderly
and due to infective and / or mechanical causes.

  • Infective agents are probably the major cause.  
    Infective agents can be isolated in > 50% of lesions,
    with mainly Candida or staphylococci being isolated.

    Candida albicans is the most commonly isolated and
    is typically carried in the saliva.  Oral candidiasis
    causing cheilitis is particularly common in those
    wearing dentures, especially where there is denture-
    related stomatitis and was probably responsible for
    some cases of cheilitis attributed to allergy to denture
    materials - since contamination of denture-material by
    Candida may cause false-positive patch-test
    reactions.  Dry mouth also predisposes to candidiasis.

    Staphylococcus aureus and / or streptococci may also
    be cultured from lesions, and may be harboured in the
    nose (anterior nares).

  • Mechanical factors may play a part in the œdentulous
    (toothless) patient who does not wear or who has
    inadequate dentures.  As a consequence of ageing,
    the upper lip overhangs the lower at the angles of the
    mouth, producing a fold that keeps a small area of
    skin macerated.  Maceration of the commissural
    epithelium can also be brought about by habitual
    licking as a nervous tic or by sucking on objects
    (perlèche).  Few authors consider that the lesion
    results solely from maceration.

  • Deficiencies of hæmatinics (factors required for blood
    formation - which include iron, vitamin B and folic
    acid) and deficiencies of immunity can lead to
    proliferation of Candida species.

  • Nutritional deficiencies, in particular, deficiencies of
    riboflavin, folate, iron, zinc and general protein
    malnutrition, have been incriminated in AC but are
    rare.  AC is, very occasionally, an isolated initial sign
    of anæmia or vitamin deficiency, such as vitamin B12
    deficiency; more often there is also oral ulceration
    and glossitis.

  • Immune deficiency such as in diabetes, Down
    syndrome or HIV disease may result in AC associated
    with candidiasis.

In uncommon conditions where the lips are enlarged, such
as
Oro-Facial Granulomatosis, up to 20% of individuals
have
angular stomatitis, although Candida species are not
often isolated.


How is it treated?

Management of AC is sometimes difficult and may need to
be prolonged.

  • Tobacco habits should be stopped.

  • Eliminate any underlying systemic pre-disposing
    factors.  Underlying systemic disease must be sought
    and treated and a course of oral iron and vitamin B
    supplements may be helpful in indolent cases.

  • The skin lesions should be swabbed (to see if there is
    an infective element to the condition).

  • If infection is the cause of AC, treatment will only be
    effective if the underlying disease process is also
    being treated.

    Permanent cure can be achieved only by eliminating
    candidiasis as well as the growth of Candida beneath
    the denture.  Recurrence of AC must be prevented by
    eliminating organisms from their reservoir (that is, the
    denture); treatment of the denture is with a topical anti-
    fungal (e.g. miconazole).

  • Staphylococcus infection can be cleared with topical
    antibiotics such as fusidic acid ointment or cream
    used at least four times daily.

  • Mixed infections of Candida and Staphylococcus
    respond best to topical miconazole.

  • Mechanical predisposing factors should be corrected.  
    A change in dentures may be necessary; new
    dentures which restore facial contour may help.

  • In rare intractable cases, surgery or, occasionally,
    collagen injections may be useful in trying to restore
    normal commissural anatomy.


Useful Websites:

Wikipedia

General Practice Notebook

Angular Cheilitis Treatment

American Association of Family Practitioners

SkinSight.com
What is Angular Cheilitis?

Angular Cheilitis (AC) is inflammation at the commissures
(angles) of the lips.

Angular Cheilitis (also called Perlèche, Cheilosis or
Angular Stomatitis) is an inflammatory lesion at the labial
commissures
(corner of the mouth) and often occurs
bilaterally (both sides).  The condition manifests as deep
cracks or splits; in severe cases, the splits can bleed when
the mouth is opened and shallow ulcers or a crust may
form.


What are the signs & symptoms?

Soreness, erythema (redness) and fissuring (cracking)
affect the angles of the mouth symmetrically.  
Angular
cheilitis
most commonly presents as roughly triangular
areas of
erythema and œdema (swelling) at both
commissures.  
Atrophy, ulceration, crusting, maceration
and
scaling may be seen.  A burning sensation and a
feeling of dryness may occur.  An
eczematous dermatitis
may extend some distance onto the cheek or chin as an
infective eczematoid reaction or as a reaction to topical
medicaments
.
In long-standing lesions, suppuration and granulation
tissue
may develop.

Lesions occasionally extend beyond the
vermilion border
onto the skin in the form of linear furrows or fissures
radiating from the angle of the mouth (
rhagades), mainly in
the more severe forms, especially in denture wearers.

Commonly, there is also associated
denture-related
stomatitis
.  Rarely, there is also commissural leukoplakia
intra-orally.
Last Updated 18th August 2010