Angular Stomatitis

Angular stomatitis (angular cheilitis) is inflammation, fissuring and maceration at the corners of the mouth. It is multifactorial: candida and staphylococcal or streptococcal infection, nutritional deficiency, denture problems and saliva pooling.

• Risk factors: ill fitting dentures, loss of vertical dimension, drooling, lip licking, thumb sucking, diabetes, HIV, iron, vitamin B12, folate, riboflavin or zinc deficiency, atopic dermatitis, inhaled corticosteroids, retinoids.
• Common in older adults, infants and children, and malnourished people.

Red, cracked, moist or crusted fissures at one or both mouth corners, painful on opening, sometimes bleeding.

• Associated glossitis, pallor or oral candidiasis suggests deficiency or candida.
• Differential diagnosis: herpes labialis, contact or atopic dermatitis, perioral dermatitis, impetigo, syphilitic split papules, Crohn disease, coeliac disease, zinc deficiency (acrodermatitis), pemphigus, Plummer Vinson syndrome, squamous cell carcinoma.
• Complications: chronic recurrence, secondary bacterial or candidal infection, scarring, difficulty eating and speaking, undiagnosed anaemia or malabsorption.

Clinical; swab for bacterial and fungal culture in chronic or resistant cases.

• Full blood count, ferritin, vitamin B12, folate, glucose or HbA1c, HIV serology.
• Denture assessment; consider zinc and coeliac serology in persistent cases.
• Biopsy for non healing lesions.

Treat infection, correct the predisposing factor and protect the skin.

• Supportive: keep the area dry, apply petroleum jelly barrier after treatment, stop lip licking, treat denture hygiene (remove at night, soak in chlorhexidine 0.2 percent or dilute hypochlorite), dental review for refitting, correct drooling.
• Pharmacological: miconazole 2 percent cream (or combined miconazole with hydrocortisone 1 percent) twice daily for 2 weeks, as it covers candida and gram positive bacteria; fusidic acid 2 percent cream three times daily for 7 days where staphylococcal infection is suspected; nystatin ointment 100,000 units/g three times daily. Nasal mupirocin 2 percent twice daily for 5 days for staphylococcal carriage. Correct deficiencies: ferrous sulfate 200 mg three times daily, vitamin B12 as hydroxocobalamin 1 mg IM on alternate days for 2 weeks, then every 3 months, when deficient, folic acid 5 mg daily, riboflavin 10 mg daily. Fluconazole 50 mg daily for 7 to 14 days for refractory candidal disease.
• Procedures: dental reconstruction or filler for deep folds; denture replacement.
• Special groups: infants, nystatin oral suspension or miconazole cream and treat drooling; pregnancy, topical agents only; diabetes, optimise glycaemic control; HIV, treat the immunosuppression.
• Red flags: persistent ulceration beyond 4 weeks, induration, bleeding, weight loss, anaemia not responding to iron, multiple mucosal sites.
• Follow-up: review at 2 weeks; if recurrent, repeat investigations and dental review.