Angular Cheilitis Due to Candida

Angular cheilitis due to Candida is inflammation, maceration and fissuring at the mouth corners in which Candida albicans, often with Staphylococcus aureus, colonises the damaged skin. Saliva pooling in the commissure creates a moist environment.

• Denture wearers, children who drool or lick their lips, and older adults with lost vertical dimension are affected.
• Diabetes, HIV, iron, B12 and folate deficiency, and inhaled corticosteroid use are risk factors.
• It is often chronic and recurrent.

Red, cracked, moist or crusted fissures at one or both corners of the mouth, burning and pain on opening, and sometimes white plaques inside the mouth.

• Differential diagnosis: staphylococcal angular cheilitis, herpes labialis, contact dermatitis, nutritional deficiency, perioral dermatitis, syphilis, Crohn disease, zinc deficiency, squamous cell carcinoma.
• Complications: chronic fissures, secondary bacterial infection, scarring, spread to the oral mucosa, nutritional compromise.

Clinical, with swab and blood tests in chronic or resistant cases.

• Swab for bacterial and fungal culture; KOH preparation.
• Full blood count, ferritin, vitamin B12, folate, glucose or HbA1c, HIV test.
• Denture and bite assessment; biopsy if a lesion fails to heal.

Antifungal treatment together with correction of the cause.

• Supportive: keep the corners dry, apply petroleum jelly barrier, stop lip licking and thumb sucking, remove dentures at night and soak in chlorhexidine 0.2 percent or dilute hypochlorite, rinse the mouth after inhaled steroids, dental review of denture fit.
• Pharmacological: miconazole 2 percent cream twice daily for 2 weeks (or combined with hydrocortisone 1 percent for the first week); clotrimazole 1 percent cream twice daily; nystatin ointment 100,000 units/g three times daily; fusidic acid 2 percent cream three times daily for 7 days if staphylococcal infection; fluconazole 50 mg daily for 7 to 14 days for resistant disease or oral candidiasis. Correct deficiencies: ferrous sulfate 200 mg three times daily, folic acid 5 mg daily, vitamin B12 1 mg IM when deficient.
• Procedures: filler or surgical correction of deep commissural folds; denture refitting.
• Special groups: pregnancy, topical agents only; children, topical miconazole and barrier cream; diabetes, glucose control; HIV, treat immunosuppression and look for oral thrush.
• Red flags: persistent ulceration beyond 4 weeks, induration, bleeding, weight loss, anaemia that does not respond.
• Follow-up: review at 2 weeks; investigate further if it recurs.