- Angular cheilitis, also known as perlèche, results from maceration, inflammation, and an overgrowth of microorganisms, especially Candida albicans, at the corners of the mouth.
- Moisture and maceration stemming from chronic exposure to saliva is an important risk factor for developing angular cheilitis; successful treatment and prevention of recurrences requires reduction of maceration and/or use of a barrier ointment to minimize ongoing exposure.
Angular cheilitis is due to a combination of local irritation, moisture, and overgrowth of microorganisms, especially C. albicans, at the corners of the mouth. It is seen in five settings: infants; edentulous, usually elderly, persons, owing to constant maceration of the angle of the mouth; adolescents and adults who wear orthodontic devices; diabetics and those who have undergone antibiotic or systemic steroid therapy; and immunosuppressed persons. In all cases, the therapeutic strategy is to eliminate the presence of microorganisms at the corners of the mouth using the appropriate anti-infective and/or by instituting appropriate steps to modify the conditions that support microorganism overgrowth in this location. The oral cavity must also be examined, and if oral candidiasis (thrush) is present it must be treated at the same time.
Angular cheilitis primarily affects the lateral oral commissures with typically symmetric involvement. In early stages, the affected skin is ill defined and macerated, with superficial erythema and erosions. As the condition develops, skin lesions may become more papular, eczematous, crusted, and may develop fissures.
Because angular cheilitis stems from chronic maceration by saliva, it is essential to address the ongoing exposure to moisture as part of the treatment plan. Other medical considerations in the differential diagnosis of angular cheilitis include: nutritional deficiency, inflammatory bowel disease, allergic contact dermatitis, and medications.
First-line therapy: The first-line therapy should address microbial overgrowth and also minimize ongoing maceration of affected sites. Treatment of concomitant oral candidiasis, when present, is also necessary.
- Infants: Oral candidiasis (thrush) is almost always present. Treatment is with oral nystatin suspension (100,000 U/ml) q.i.d., plus application of nystatin ointment to the affected area b.i.d. for 1 week. Topically applied Gentian violet is a highly effective alternative if the purple discoloration of lips and mouth are acceptable. Excess food and saliva should be carefully washed from the affected area regularly.
- Elderly edentulous persons: Refer the patient to a dental specialist to adjust the dentures, adding vertical dimension. Treat oral thrush if present. Have the patient clean the denture(s) in an appropriate disinfecting solution daily, and apply topical nystatin ointment or a topical imidazole cream to the affected area t.i.d. for 2 weeks. Use of clotrimazole troches to prevent recurrent oral thrush may be helpful.
- Diabetics and post antibiotic/systemic steroid patients: Treat thrush if present. Have the patient apply topical nystatin ointment or a topical imidazole cream to the perlèche t.i.d. for 2 weeks. Use of clotrimazole troches to prevent recurrent oral thrush may be helpful.
- Immunosuppressed patients: Treat thrush if present. Have the patient apply topical nystatin ointment or a topical imidazole cream to the perlèche t.i.d. Topical therapy may need to be maintained if immunosuppression persists.
- In all patients, consistent use of a barrier ointment, such as petrolatum or zinc oxide ointment, in between antimicrobial treatments, prevents ongoing maceration of the affected areas and promotes healing.
- When intense inflammation is present, addition of a low-potency topical corticosteroid ointment (such as desonide 0.05% ointment) to the anticandidal therapy may enhance resolution of erythema and healing of erosions.
- If mild, angular cheilitis may be treated with hydrocortisone 1% cream/ iodoquinol 1% cream applied b.i.d. to t.i.d. The iodoquinol has antimicrobial activity.
- In the elderly, edentulous patient, redundant folded skin at the comers of the mouth may predispose to perlèche and may need to be corrected for the perlèche to clear. Collagen injections or surgery may be necessary.
- Secondary bacterial infection may occur and requires topical or systemic antibiotics, as for impetigo. Common bacterial pathogens complicating angular cheilitis include Staphylococcus and Streptococcus species.
- For refractory adult cases prescribe fluconazole tablets 100 mg daily for one week followed by 150 mg weekly for 6 weeks’ duration.
- Evaluation for immunosuppression is indicated if other predisposing factors are not identified.
- Clotrimazole troches and oral fluconazole may cause liver function abnormalities.
- Ointment-based treatments, when possible, are recommended. They are nonsensitizing and ointment occlusion of the area prevents maceration and enhances response.
- Habitual lip licking or thumb sucking (in children) can be a cause of angular cheilitis.
- If the patient is pruritic, suspect allergic contact dermatitis. Common allergic contactants causing angular cheilitis include flavorings, fragrances, metals, sunscreens, preservatives, medications, and other components of dental hygiene products or lip cosmetics (such as sodium laurel sulfate, emollients, colophony, cocamidopropyl betaine).
- Metabolic diseases and nutritional deficiencies (such as iron, riboflavin or vitamin B12, pyridoxine, folic acid, niacin, and zinc deficiencies) are rare causes of perlèche.
- Perlèche, especially when unilateral, that fails to respond as expected may be a sign of a mucocutaneous malignancy.
- In edentulous and immunosuppressed patients, candidiasis may recur very quickly, and preventive therapy consisting of an application of a barrier ointment such as petrolatum, zinc oxide, or use of an imidazole cream q.d. may be necessary to prevent recurrences.
- Failure to identify oral candidiasis (thrush) may result in rapid relapse of the angular cheilitis.
When to refer to a dermatologist
- When the diagnosis of angular cheilitis is not clear
- If a superimposed allergic contact dermatitis is suspected
- 68-year-old healthy female
- No significant past medical history
- Edentulous with ill-fitting dentures
- Presents for evaluation and management of long-standing “lip ulcers”
- Healthy appearing female
- Perioral crusted erythematous crusted papules, with erythema and fissuring at bilateral lateral oral commissures
- No evidence of oral candidiasis on exam
- Nystatin ointment t.i.d. to affected areas
- Recommend frequent application of barrier ointment (petrolatum) throughout the day to avoid ongoing maceration
- Recommend soaking dentures nightly in appropriate denture disinfecting solution
- Referral to dentist for denture-fitting
- Follow-up in 2 weeks (much improved)
Park KK, Brodell RT, Helms SE (2011) Angular cheilitis, part 1: local etiologies, Cutis, 87(6):289-295.
Park KK, Brodell RT, Helms SE (2011) Angular cheilitis, part 2: nutritional, systemic, and drug-related causes and treament, Cutis, 87(1):27-32.
Sharon V, Fazel N (2010) Oral candidiasis and angular cheilitis, Dermatologic Therapy, 23: 230-242.