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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?

Predisposing Factors

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
    isolated.

    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
    candidiasis.

    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
    the condition).

  • 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
    miconazole.

  • 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:

Wikipedia

General Practice Notebook

Angular Cheilitis Treatment

American Association of Family Practitioners

SkinSight.com

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
form.


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
medicaments
.
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
intra-orally.
Last Updated 19th September 2011