|Angular Cheilitis / Angular Stomatitis
How is it Diagnosed?
This is usually a clinical diagnosis, made by clinical examination alone.
Angular cheilitis accompanied by alopecia, diarrhoea and
non-specific oral ulcerations, most commonly of the tongue and buccal mucosa,
may suggest zinc deficiency.
What are the causes of Angular Cheilitis?
AC is predisposed by what are known as the '3Ds'.
Denture-wearing and disorders that predispose to Candidiasis:
Deficiency states such as:
- iron deficiency
- hypovitaminoses (especially B)
- mal-absorption states (e.g. Crohn's disease)
- possibly zinc deficiency (rarely)
- defects in immunity such as in Down syndrome, HIV infection, diabetes,
cancer and others.
Disorders where the lips are enlarged, such as oro-facial granulomatosis, Crohn's
disease and Down syndrome.
A number of factors (infective, mechanical, nutritional or immunological) may be
implicated alone or in combination. AC is most often chronic, seen in the elderly
and due to infective and / or mechanical causes.
- Infective agents are probably the major cause. Infective agents can be
isolated in > 50% of lesions, with mainly Candida or staphylococci being
Candida albicans is the most commonly isolated and is typically carried in the
saliva. Oral candidiasis causing cheilitis is particularly common in those
wearing dentures, especially where there is denture-related stomatitis and
was probably responsible for some cases of cheilitis attributed to allergy to
denture materials - since contamination of denture-material by Candida may
cause false-positive patch-test reactions. Dry mouth also predisposes to
Staphylococcus aureus and / or streptococci may also be cultured from
lesions, and may be harboured in the nose (anterior nares).
- Mechanical factors may play a part in the œdentulous (toothless) patient who
does not wear or who has inadequate dentures. As a consequence of ageing,
the upper lip overhangs the lower at the angles of the mouth, producing a fold
that keeps a small area of skin macerated. Maceration of the commissural
epithelium can also be brought about by habitual licking as a nervous tic or by
sucking on objects (perlèche). Few authors consider that the lesion results
solely from maceration.
- Deficiencies of hæmatinics (factors required for blood formation - which
include iron, vitamin B and folic acid) and deficiencies of immunity can lead to
proliferation of Candida species.
- Nutritional deficiencies, in particular, deficiencies of riboflavin, folate, iron,
zinc and general protein malnutrition, have been incriminated in AC but are
rare. AC is, very occasionally, an isolated initial sign of anæmia or vitamin
deficiency, such as vitamin B12 deficiency; more often there is also oral
ulceration and glossitis.
- Immune deficiency such as in diabetes, Down syndrome or HIV disease may
result in AC associated with candidiasis.
In uncommon conditions where the lips are enlarged, such as Oro-Facial
Granulomatosis, up to 20% of individuals have angular stomatitis, although
Candida species are not often isolated.
How is it treated?
Management of AC is sometimes difficult and may need to be prolonged.
- Tobacco habits should be stopped.
- Eliminate any underlying systemic pre-disposing factors. Underlying systemic
disease must be sought and treated and a course of oral iron and vitamin B
supplements may be helpful in indolent cases.
- The skin lesions should be swabbed (to see if there is an infective element to
- If infection is the cause of AC, treatment will only be effective if the underlying
disease process is also being treated.
Permanent cure can be achieved only by eliminating candidiasis as well as the
growth of Candida beneath the denture. Recurrence of AC must be prevented
by eliminating organisms from their reservoir (that is, the denture); treatment
of the denture is with a topical anti-fungal (e.g. miconazole).
- Staphylococcus infection can be cleared with topical antibiotics such as fusidic
acid ointment or cream used at least four times daily.
- Mixed infections of Candida and Staphylococcus respond best to topical
- Mechanical predisposing factors should be corrected. A change in dentures
may be necessary; new dentures which restore facial contour may help.
- In rare intractable cases, surgery or, occasionally, collagen injections may be
useful in trying to restore normal commissural anatomy.
Useful Websites & Article:
General Practice Notebook
Angular Cheilitis Treatment
American Association of Family Practitioners
National Center for Emergency Medicine Informatics (Perlèche)
Canadian Family Physician 2007. Dermacase Answer. 3. Angular Cheilitis
What is Angular Cheilitis?
Angular Cheilitis (AC) is inflammation at the
commissures (angles) of the lips.
Angular Cheilitis (also called Perlèche, Cheilosis or
Angular Stomatitis) is an inflammatory lesion at the labial
commissures (corner of the mouth) and often occurs
bilaterally (both sides). The condition manifests as deep
cracks or splits; in severe cases, the splits can bleed when
the mouth is opened and shallow ulcers or a crust may
What are the signs & symptoms?
Soreness, erythema (redness) and fissuring (cracking)
affect the angles of the mouth symmetrically. Angular
cheilitis most commonly presents as roughly triangular
areas of erythema and œdema (swelling) at both
commissures. Atrophy, ulceration, crusting, maceration
and scaling may be seen. A burning sensation and a
feeling of dryness may occur. An eczematous dermatitis
may extend some distance onto the cheek or chin as an
infective eczematoid reaction or as a reaction to topical
In long-standing lesions, suppuration and granulation
tissue may develop.
Lesions occasionally extend beyond the vermilion border
onto the skin in the form of linear furrows or fissures
radiating from the angle of the mouth (rhagades), mainly in
the more severe forms, especially in denture wearers.
Commonly, there is also associated denture-related
stomatitis. Rarely, there is also commissural leukoplakia
|Last Updated 19th September 2011