Candidal Cheilitis

Candidal cheilitis is a chronic inflammation of the lips and vermilion, with scaling, fissuring and erythema, in which Candida albicans colonises or infects damaged lip epithelium. It often coexists with angular stomatitis.

• Risk factors: chronic lip licking, dry lips, mouth breathing, dentures, inhaled or topical corticosteroids, diabetes, HIV, broad spectrum antibiotics, smoking, xerostomia.
• Seen in children who lick or suck the lips, in smokers and in older adults.

Dry scaly, red, fissured lips with persistent burning and soreness, often involving the lower lip and corners of the mouth.

• Associated oral candidiasis or denture stomatitis.
• Differential diagnosis: actinic cheilitis, allergic or irritant contact cheilitis, atopic cheilitis, exfoliative cheilitis, granulomatous cheilitis, lichen planus, herpes labialis, lupus, squamous cell carcinoma, vitamin deficiency cheilitis, drug reaction (retinoids).
• Complications: chronic fissuring and bleeding, secondary bacterial infection, spread to oral and oesophageal mucosa in immunosuppression, scarring, malignant transformation when associated with leukoplakia or actinic damage.

Clinical with swab or scraping for KOH and culture.

• Glucose or HbA1c, HIV test, full blood count, haematinics.
• Patch testing for suspected contact cheilitis (lipsticks, toothpaste, flavourings).
• Biopsy for persistent, indurated or leukoplakic changes.

Eradicate Candida and restore the lip barrier.

• Supportive: stop lip licking and picking, apply plain petroleum jelly frequently, avoid irritant lip products and flavoured toothpaste, drink plenty of water, treat dentures, correct mouth breathing.
• Pharmacological: clotrimazole 1 percent or miconazole 2 percent cream three times daily for 2 to 4 weeks; nystatin ointment 100,000 units/g three times daily; combination antifungal and hydrocortisone 1 percent cream for 5 to 7 days when inflammation is marked. Oral fluconazole 100 mg daily for 7 to 14 days or itraconazole oral solution 200 mg daily for 7 to 14 days in resistant cases.
• Procedures: biopsy; lip shave or cryotherapy for actinic change.
• Special groups: pregnancy, topical azoles or nystatin; children, nystatin or topical miconazole, treat habits; denture wearers, disinfect the denture daily and leave it out overnight; HIV, start or optimise antiretroviral therapy.
• Red flags: ulcer or induration, persistent white patch, non response at 4 weeks, weight loss, associated lymphadenopathy.
• Follow-up: review at 2 to 4 weeks; biopsy if not resolved by 6 to 8 weeks.