What is the treatment for angular cheilitis?

Treatment for Angular Cheilitis

The most effective treatment for angular cheilitis is a combination antifungal-corticosteroid ointment such as 1% isoconazole nitrate with 0.1% diflucortolone valerate applied to affected areas 1-3 times daily until resolution. 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

Etiology and Diagnosis

Angular cheilitis typically has a mixed etiology:

1. Infectious causes:

   • Fungal (primarily Candida species)
   • Bacterial (commonly Staphylococcus aureus)
   • Mixed infections

2. Contributing factors:

   • Decreased vertical dimension of occlusion
   • Ill-fitting dentures
   • Poor oral hygiene
   • Nutritional deficiencies
   • Drooling or excessive moisture at lip corners
   • Advanced age
   • Immunocompromised status

Treatment Algorithm

Step 1: Topical Antimicrobial Therapy

• First-line treatment: Combined antifungal-corticosteroid preparation

  • 1% isoconazole nitrate with 0.1% diflucortolone valerate ointment applied 1-3 times daily 1
  • Alternative: Miconazole/fusidic acid combination 2

• For predominantly bacterial infection:

  • Bacitracin ointment applied 1-3 times daily 3

• For predominantly fungal infection:

  • Topical antifungal (miconazole, clotrimazole, nystatin)

Step 2: Address Contributing Factors

• Correct ill-fitting dentures if present
• Improve oral hygiene
• Address nutritional deficiencies (particularly B vitamins)
• Manage underlying systemic conditions

Step 3: For Refractory Cases

• Consider photodynamic therapy (PDT) for persistent cases 4
• Evaluate for underlying systemic conditions
• Consider oral antifungals if topical treatment fails

Special Considerations

1. Denture wearers:

   • Denture adjustment or replacement may be necessary
   • Denture cleaning and removal at night is essential

2. Immunocompromised patients:

   • May require more aggressive or prolonged therapy
   • Higher risk of fungal resistance

3. Recurrent cases:

   • Investigate for underlying systemic conditions
   • Consider maintenance therapy

Application Instructions

• Clean the affected area thoroughly
• Apply a small amount of medication (approximately the size of a fingertip) to the corners of the mouth
• Apply 1-3 times daily as directed
• Continue treatment until complete resolution plus 2-3 days to prevent recurrence
• May cover with sterile bandage if appropriate

Treatment Efficacy

The combination of antifungal and anti-inflammatory agents is most effective because:

• Addresses both infectious and inflammatory components
• Isoconazole nitrate provides broad-spectrum activity against dermatophytes and bacteria
• Diflucortolone valerate reduces inflammation and discomfort 1

Common Pitfalls to Avoid

1. Inadequate treatment duration - Continue treatment until complete resolution plus several additional days
2. Failure to address underlying causes - Simply treating symptoms without addressing contributing factors leads to recurrence
3. Misdiagnosis - Angular cheilitis may be confused with herpes labialis, contact dermatitis, or other conditions
4. Overuse of corticosteroids - Can lead to skin atrophy with prolonged use
5. Neglecting oral hygiene - Essential component of successful treatment and prevention

Angular cheilitis is a multifactorial condition that requires addressing both the infection and underlying contributing factors for successful resolution and prevention of recurrence.