What is the treatment for angular cheilitis?

Treatment of Angular Cheilitis

The most effective treatment for angular cheilitis is a combination of antifungal and anti-inflammatory agents, specifically 1% isoconazole nitrate with 0.1% diflucortolone valerate ointment, applied to affected areas 2-3 times daily until resolution. 1

Diagnostic Considerations

Angular cheilitis presents as erythema, fissures, ulcerations, and crusting at the corners of the mouth. Before initiating treatment, consider these key factors:

• Mixed etiology (fungal and bacterial components) 2
• Potential underlying conditions:
  • Iron deficiency, especially in women of childbearing age 3
  • Poor-fitting dentures in elderly patients 4
  • Local irritants or allergic factors 5

Treatment Algorithm

Step 1: Topical Antimicrobial Therapy

• First-line treatment: Apply combination antifungal/corticosteroid ointment (1% isoconazole nitrate with 0.1% diflucortolone valerate) 2-3 times daily 1
  • The antifungal component addresses Candida species
  • The corticosteroid reduces inflammation and discomfort

Step 2: Address Specific Etiologies

• For denture wearers:

  • Clean dentures thoroughly daily
  • Remove dentures before performing oral care 6
  • Consider soaking dentures in antimicrobial solution (e.g., chlorhexidine 0.2%) for 10 minutes 6

• For suspected candidal infection:

  • Take oral and lip swabs if secondary infection is suspected
  • Consider nystatin oral suspension 100,000 units four times daily for 1 week, or miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 6

• For severe cases with significant inflammation:

  • Apply topical corticosteroid four times daily (e.g., betamethasone sodium phosphate 0.5 mg in 10 mL water as rinse-and-spit) 6
  • For more potent treatment, clobetasol propionate 0.05% mixed with equal amounts of Orabase can be applied directly to affected areas 6

Step 3: Supportive Care

• Apply white soft paraffin ointment to the lips every 2 hours 6
• Maintain adequate hydration to keep mouth moist 6
• Use antiseptic oral rinse twice daily (e.g., 0.2% chlorhexidine digluconate mouthwash) 6
• Consider diluting chlorhexidine mouthwash by up to 50% to reduce soreness 6

Special Considerations

Iron Deficiency

• Consider iron studies in patients with recurrent angular cheilitis, especially women of childbearing age 3
• Iron supplementation may be necessary to address underlying deficiency

Denture-Related Issues

• Evaluate fit of dentures and consider adjustment if necessary 4
• Defer wearing dental prostheses as much as possible until healing occurs 6

Preventive Measures

• Maintain good oral hygiene with regular brushing using a soft toothbrush 6
• Avoid irritants such as spicy foods, citrus fruits, and alcohol 6
• Inspect oral mucosa daily for early signs of recurrence 6

Common Pitfalls to Avoid

1. Treating only the fungal component - Angular cheilitis often has mixed etiology requiring both antifungal and anti-inflammatory treatment 1

2. Overlooking underlying conditions - Iron deficiency and ill-fitting dentures are common predisposing factors that must be addressed for complete resolution 4, 3

3. Prolonged use of petroleum jelly - While providing temporary relief, chronic use of petroleum jelly can promote mucosal dehydration and increase risk of secondary infection 6

4. Inadequate duration of treatment - Continue treatment until complete resolution to prevent recurrence

5. Failure to modify oral hygiene practices - Maintaining proper oral hygiene is essential for preventing recurrence 6