Chapter 32. Angular Cheilitis

A middle-aged woman presents to your office with soreness at the corners of her mouth for 4 months (Figure 32-1). On examination, she has cracking and fissures at the right corner of her mouth. She is diagnosed with angular cheilitis and treated with nonprescription nystatin ointment twice daily. Within 2 weeks she was fully healed.

Angular cheilitis is an inflammatory lesion of the commissure or corner of the lip characterized by scaling and fissuring.

Perlèche, angular cheilosis, commissural cheilitis, angular stomatitis

• Most common in the elderly. In one study of institutionalized elderly patients in Scotland, angular cheilitis was present in 25% of patients.1

• Maceration is the usual predisposing factor. Microorganisms, most often Candida albicans, can then invade the macerated area (Figure 32-2).2
• It may also occur in infants and children related to drooling, thumb sucking, and lip licking (Figure 32-3).
• Lip licking can cause a contact dermatitis to the saliva along with perlèche (Figure 32-4). Perlèche is derived from the French word, “lecher,” meaning to lick.
• Historically associated with vitamin B deficiency, which is rare in developed countries.

• Maceration which can be related to poor dentition, deep facial wrinkles, orthodontic treatment, or poorly fitting dentures in the elderly (Figure 32-5).
• Other risk factors include incorrect use of dental floss causing trauma or diseases that enlarge the lips such as orofacial granulomatosis.
• Atopic dermatitis (Figure 32-6).
• HIV or other types of immunodeficiency may lead to more severe case of angular cheilitis with overgrowth of Candida (Figure 32-7).
• Use of isotretinoin which dries the lips and predisposes to angular cheilitis.^57672324

Clinical Features

• Erythema and fissuring at the corners of the mouth, without exudates or ulceration (Figures 32-3, 32-4, 32-5, 32-6, and 32-7).

Typical Distribution

• Corners of the mouth (oral commissures or angles of the mouth) hence the names commissural cheilitis and angular cheilitis.

Labs

• A light scraping of the corner of the mouth can be placed on a slide with KOH to look for Candida (Figure 32-2).

Biopsy

• Not usually indicated.

• Impetigo—Yellowish crusts or exudates are characteristic of impetigo but not angular cheilitis (see Chapter 116, Impetigo).
• Herpes simplex (cold sores)—Initial blisters, followed by shallow ulcers, are characteristic of herpes simplex, but not angular cheilitis (see Chapter 129, Herpes Simplex).

Nonpharmacologic

• Attempt to relieve precipitating causes such as poorly fitting dentures.
• Counsel patients to stop licking their lips if this is part of the cause (Figure 32-4).
• Recommend protective petrolatum or lip balm as needed.
• Counsel patients to stop using tobacco, either chewing or smoking.

Medications

• Recommend topical antifungal creams or ointments, such as clotrimazole, to be applied twice daily.3 SOR B
• Low-potency topical corticosteroid, such as 1% hydrocortisone cream twice daily, may be added to treat the inflammatory component. SOR B
• Nystatin lozenges work well but their use is limited because of their unpleasant taste.3 SOR C If thrush is also present, prescribe clotrimazole troches for treatment of both conditions.
• One randomized controlled study showed that medicated chewing gum can decrease the risk of angular cheilitis in older occupants of nursing homes. Consider recommending xylitol-containing gum to elderly patients with angular cheilitis.4 SOR B

Attempt to identify predisposing factors and correct if possible, such as:

• Edentulousness.
• Poorly fitting dentures.
• Drooling.
• Lip licking (Figure 32-4)
• Atopic dermatitis (Figures 32-3 and 32-6)

Protective lip balm may be helpful to prevent recurrences as long as the patient is not allergic to chemicals within the product. Plain petrolatum is often the safest product for dry lips.

• Encourage patients to identify and correct predisposing factors (as above). Protective lip balm may be helpful.

Patient and Provider Resources

• http://www.stevedds.com/toppage2.htm#Angular Chelitis.
• http://www.ncemi.org/cse/cse0409.htm.