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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:


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 & Article:

Wikipedia

General Practice Notebook

Angular Cheilitis Treatment

American Association of Family Practitioners

SkinSight.com

National Center for Emergency Medicine Informatics (Perlèche)

ScienceDirect

Primary Care Dermatology Society


Useful Articles:

Canadian Family Physician 2007.  Dermacase Answer.  3. Angular Cheilitis

Ind J Dent Res 2017.  Angular Cheilitis - A Clinical & Microbial Study

StatPearls 20019.  Angular Cheilitis

Proceedings 2019.  Photodynamic Therapy in Non-Responsive Oral Angular Cheilitis - 4 Case Reports

Oral Surg Oral Med Oral Path Oral Rad 2020.  Hyaluronic Acid Dermal Fillers in the Management of Recurrent
Angular Cheilitis - A Case Report
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 29th December 2019