Angular Cheilitis

Angular cheilitis (perleche, angular stomatitis) is an inflammatory condition of the skin and mucosa at one or both corners of the mouth, producing erythema, fissuring, crusting and soreness. It is common at all ages, with a higher prevalence in the elderly, denture wearers and children who lick their lips.

The cause is multifactorial. Local factors cause moisture accumulation at the commissure: saliva pooling from reduced vertical dimension (edentulous patients, ill fitting or worn dentures), deep folds at the angle in older people, drooling, lip licking, thumb sucking, and mouth breathing.

Infection follows: Candida albicans (about 60 percent), Staphylococcus aureus (about 20 percent), or both, and occasionally beta haemolytic streptococci and herpes simplex virus. Systemic contributors are iron deficiency, vitamin B2, B6, B12 and folate deficiency, zinc deficiency, diabetes mellitus, HIV, immunosuppression, inflammatory bowel disease, coeliac disease, Down syndrome, and isotretinoin therapy. Recurrence is common without correcting the cause.

• Red, cracked, fissured skin at one or both corners of the mouth, often with crusting, maceration, bleeding on opening the mouth, and soreness or burning.
• Whitish moist maceration (candidal), golden crust (staphylococcal), or deep fissure.
• Associated oral findings: denture stomatitis, oral candidiasis, atrophic glossitis (nutritional deficiency), dry mouth.
• Itch, pain on eating or opening the mouth, and sometimes dysphagia.
• Red flags: persistent lesion beyond 4 weeks despite treatment (biopsy), induration, ulceration with an irregular border, unexplained anaemia or weight loss, systemic features of immunosuppression, and lesions elsewhere (consider Crohn disease, acrodermatitis enteropathica).

• Clinical diagnosis from appearance; assess denture fit, occlusal vertical dimension, and lip folds.
• Swab for bacterial culture and Candida culture or KOH smear from the commissure and the oral cavity or denture surface.
• Blood tests for recurrent or persistent lesions: full blood count, ferritin, vitamin B12, folate, zinc, glucose or HbA1c, and HIV test; coeliac serology (tissue transglutaminase IgA with total IgA).
• Patch testing for contact dermatitis (lip balms, toothpaste, cosmetics, flavourings, dental materials).
• Biopsy for non-healing lesions to exclude carcinoma and granulomatous disease.
• Exclude herpes labialis, contact dermatitis, impetigo, syphilitic fissures, lichen planus, pemphigus, and squamous cell carcinoma.

• Candidal or mixed infection: miconazole 2 percent cream or clotrimazole 1 percent cream applied to the corners 3 to 4 times daily for 14 days (continue 7 days after healing); for stubborn cases, combined miconazole 2 percent with hydrocortisone 1 percent cream twice daily for 7 to 14 days (steroids are used only briefly).
• Staphylococcal infection: fusidic acid 2 percent cream applied 3 times daily for 7 days, or mupirocin 2 percent ointment 3 times daily for 7 days; for extensive disease, flucloxacillin 500 mg orally every 6 hours for 7 days.
• Denture stomatitis: remove dentures at night and soak in sodium hypochlorite 0.1 percent or chlorhexidine 0.2 percent solution for 15 minutes daily, with nystatin oral suspension 100 000 units/mL, 1 mL applied to the fitting surface 4 times daily for 14 days, and replacement of ill fitting dentures.
• Barrier protection after healing: petroleum jelly or zinc oxide ointment applied at the corners 2 to 3 times daily; stop lip licking, use lip balm.
• Correct deficiency: ferrous sulfate 200 mg orally three times daily for 3 months (to restore ferritin), vitamin B12 1 mg intramuscularly alternate days for 2 weeks and then every 3 months, folic acid 5 mg daily for 4 months, riboflavin 10 mg daily, zinc sulfate 220 mg daily for 8 weeks; treat diabetes and HIV.
• Dental correction: increase the vertical dimension of dentures or reconstruct; filler or surgical correction of deep folds in recalcitrant cases.
• Children: treat with age appropriate dosing (miconazole cream twice daily for 7 to 14 days), and manage lip licking.
• Follow up: 2 weeks to confirm resolution; review underlying causes at 4 to 6 weeks, and persistent lesions need biopsy.
• Counselling: recurrence is frequent; keep corners dry and clean, and keep dentures clean.