|Angular Cheilitis / Angular Stomatitis
How is it Diagnosed?
This is usually a clinical diagnosis, made by clinical
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?
AC is predisposed by what are known as the '3Ds'.
Denture-wearing and disorders that predispose to
- 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
- Immune deficiency such as in diabetes, Down
syndrome or HIV disease may result in AC associated
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
How is it treated?
Management of AC is sometimes difficult and may need to
- 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
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.
General Practice Notebook
Angular Cheilitis Treatment
American Association of Family Practitioners
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
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
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
|Last Updated 18th August 2010