What is the treatment for angular cheilitis?

Treatment of Angular Cheilitis

The treatment of angular cheilitis should include antifungal and anti-inflammatory agents, with a combination of 1% isoconazole nitrate and 0.1% diflucortolone valerate ointment being the most effective approach due to its broad-spectrum activity against fungi and bacteria while reducing inflammation. 1

Understanding Angular Cheilitis

Angular cheilitis is an inflammatory condition affecting the corners of the mouth, characterized by:

• Erythema (redness)
• Rhagades (fissures/cracks)
• Ulcerations
• Crusting at one or both lip commissures

It has a mixed etiology, typically involving both fungal and bacterial components, with two age peaks: during childhood and in older adults 2.

Diagnostic Considerations

Before initiating treatment, consider:

• Microbial assessment: Angular cheilitis is commonly associated with Candida albicans and/or Staphylococcus aureus infections 3
• Underlying conditions: Check for:
  • Iron deficiency (particularly in women of childbearing age) 4
  • Poor-fitting dentures
  • Decreased vertical dimension of occlusion
  • Vitamin B deficiencies
  • Immunosuppression (including HIV)
  • Skin disorders associated with dry skin 3

Treatment Algorithm

First-line Treatment:

1. Topical combination therapy:

   • Antifungal + corticosteroid combination (e.g., 1% isoconazole nitrate and 0.1% diflucortolone valerate ointment) 1
   • Apply to affected areas 2-3 times daily for 7-14 days

2. Alternative topical options:

   • Miconazole/fusidic acid combination (effective against both fungal and bacterial components) 5
   • Nystatin oral suspension for confirmed candidal infections 6
   • Topical corticosteroids for inflammatory component 6

For Denture Wearers:

• Remove dentures before performing oral care
• Clean dentures thoroughly with toothpaste and rinse with water
• Consider soaking dentures in antimicrobial solution (e.g., chlorhexidine 0.2%) for 10 minutes before reinsertion 6
• Evaluate need for denture adjustment or replacement

Addressing Underlying Causes:

• Iron deficiency: Consider iron supplementation if deficiency is confirmed 4
• B vitamin deficiencies: Supplement as needed
• Oral hygiene measures:
  • Regular brushing with soft toothbrush
  • Use of alcohol-free mouthwash
  • Lubricate lips with petroleum jelly or lip balm (short-term use only) 6

Special Considerations

For HIV-Infected Patients:

Angular cheilitis may be a manifestation of oropharyngeal candidiasis, which is common in HIV patients with CD4+ counts <200 cells/μL 6. Treatment should address both conditions.

For Recurrent Cases:

Recurrence rates are high (80% within 5 years) 3, suggesting need for:

• Maintenance therapy
• Addressing underlying predisposing factors
• Regular follow-up

Treatment Pitfalls to Avoid

1. Treating symptoms without addressing causes: Investigate and treat underlying conditions like iron deficiency, vitamin deficiencies, or denture problems 4

2. Overuse of petroleum jelly: While effective for short-term lubrication, chronic use promotes mucosal dehydration and increases risk of secondary infection 6

3. Inadequate treatment duration: Complete the full course of antifungal/antibacterial treatment even if symptoms improve quickly

4. Neglecting unusual pathogens: In refractory cases, consider atypical organisms like Cystobasidium species that may require molecular identification 5

5. Ignoring recurrence risk: Patients should be informed about the high likelihood of recurrence (80%) and educated about preventive measures 3

By following this comprehensive approach to treatment and addressing underlying causes, most cases of angular cheilitis can be effectively managed, though patients should be aware of the possibility of recurrence requiring additional treatment.