What conditions are associated with angular cheilitis?

Conditions Associated with Angular Cheilitis

Angular cheilitis is commonly associated with nutritional deficiencies (particularly riboflavin, folate, and vitamin B6), fungal or bacterial infections, and systemic conditions like HIV infection and Sjögren's syndrome. 1

Primary Etiological Factors

Nutritional Deficiencies

• Riboflavin (Vitamin B2) deficiency: Manifests as oral-buccal lesions including angular stomatitis, glossitis, and cheilosis 1
• Folate deficiency: Causes angular stomatitis, glossitis, and oral ulcers 1
• Vitamin B6 (Pyridoxine) deficiency: Results in seborrheic dermatitis with cheilosis, glossitis, and angular stomatitis 1
• Iron deficiency anemia: Can present with angular stomatitis, glossitis, and koilonychia 1

Infectious Causes

• Candida albicans: Most common infectious cause, particularly in immunocompromised patients 1
• Bacterial infections: Often co-exist with fungal infections, commonly involving Staphylococcus aureus, Moraxella catarrhalis, and other organisms 1

Systemic Conditions

• HIV infection/AIDS: Angular cheilitis is recognized as a common manifestation, particularly in advanced immunosuppression 1
• Sjögren's syndrome: Angular cheilitis is listed as a key oral symptom when evaluating patients for potential Sjögren's 1

Risk Factors and Contributing Conditions

Mechanical/Anatomical Factors

• Loss of vertical dimension: Often seen in elderly patients with ill-fitting dentures or tooth loss 2, 3
• Drooling: Creates persistent moisture at the corners of the mouth 3

Immunocompromised States

• Advanced HIV disease: Particularly with CD4+ counts <200 cells/µL 1
• Diabetes mellitus: Increases susceptibility to fungal infections 1

Age-Related Factors

• Bimodal age distribution: Peaks in childhood and again in older adults 3
• Increased frequency with aging: Due to multiple contributing factors including nutritional status, denture use, and immunosenescence 3

Clinical Approach to Diagnosis

When evaluating angular cheilitis, consider:

1. Nutritional assessment: Check for deficiencies in:

   • Riboflavin
   • Folate
   • Vitamin B6
   • Iron (complete blood count)

2. Infectious evaluation:

   • Scraping for microscopic examination with potassium hydroxide (KOH) preparation to identify fungal elements 1
   • Culture to identify specific pathogens when needed

3. Systemic disease screening:

   • HIV testing when risk factors are present
   • Evaluation for Sjögren's syndrome if other symptoms are present
   • Assessment for diabetes mellitus

4. Mechanical factors:

   • Dental evaluation for vertical dimension issues
   • Assessment of denture fit in denture wearers

Treatment Considerations

Treatment should target the underlying cause:

• Nutritional deficiencies: Appropriate supplementation of the deficient vitamin or mineral
• Fungal infections: Topical antifungal agents (often combined with mild corticosteroids)
• Bacterial infections: Topical antibiotics when bacterial involvement is confirmed
• Mixed infections: Combination antimicrobial therapy
• Mechanical factors: Dental intervention to restore vertical dimension when indicated

Important Clinical Pearls

• Angular cheilitis is often multifactorial, requiring treatment of all contributing causes
• Persistent angular cheilitis should prompt evaluation for underlying systemic conditions
• In elderly patients, consider both nutritional and mechanical factors
• In HIV-infected patients, angular cheilitis may indicate progressive immunodeficiency
• Recurrent episodes warrant comprehensive evaluation for nutritional deficiencies

Angular cheilitis may be a visible marker of important underlying conditions, making thorough evaluation essential for proper management and prevention of recurrence.