What is the root cause of angular cheilitis?

Root Causes of Angular Cheilitis

Angular cheilitis is primarily caused by a combination of factors including nutritional deficiencies (particularly riboflavin, folate, vitamin B6, and iron), fungal and bacterial infections, and underlying systemic conditions such as HIV infection and Sjögren's syndrome. 1

Nutritional Deficiencies

• Vitamin B deficiencies:
  • Riboflavin (B2) deficiency manifests as oral-buccal lesions including angular stomatitis 1
  • Folate deficiency causes angular stomatitis and oral ulcers 1
  • Vitamin B6 (Pyridoxine) deficiency results in cheilosis and angular stomatitis 1
• Iron deficiency is a frequently overlooked predisposing factor, especially in women of childbearing age 2, 1

Infectious Causes

• Fungal infections:
  • Candida albicans is the most common infectious cause 1
  • Particularly prevalent in immunocompromised patients
• Bacterial infections:
  • Often co-exist with fungal infections
  • Common organisms include Staphylococcus aureus and Moraxella catarrhalis 1

Systemic Conditions

• HIV infection/AIDS:
  • Angular cheilitis is a common manifestation, especially with CD4+ counts <200 cells/µL 1
• Sjögren's syndrome:
  • Angular cheilitis is a key oral symptom 1
• Diabetes mellitus:
  • Increases susceptibility to fungal infections that can cause angular cheilitis 1

Mechanical and Environmental Factors

• Irritants:
  • Climatic factors (cold, wind)
  • Mechanical irritation
  • Caustic agents 3
• Moisture accumulation:
  • Drooling
  • Deep skin folds at the corners of the mouth (often in elderly patients with decreased vertical dimension) 1

Age-Related Patterns

• Angular cheilitis has two age peaks:
  • During childhood
  • In adults, becoming more frequent with aging 4

Diagnostic Approach

When evaluating angular cheilitis, consider:

1. Nutritional assessment (riboflavin, folate, vitamin B6, iron)
2. Infectious evaluation (fungal and bacterial cultures)
3. Systemic disease screening
4. Assessment of mechanical factors 1

Treatment Considerations

Treatment should target the underlying cause rather than just symptoms. Using antifungal agents alone may address only the symptoms without treating the predisposing cause 2.

Common Pitfalls

• Overlooking nutritional deficiencies: Iron deficiency is frequently missed as a cause, especially in women of childbearing age 2
• Treating only the infection: Focusing solely on fungal/bacterial components without addressing underlying causes leads to recurrence 1, 2
• Missing systemic conditions: Angular cheilitis may be the presenting sign of conditions like HIV or Sjögren's syndrome 1

Understanding the multifactorial nature of angular cheilitis is essential for effective diagnosis and treatment, as the condition rarely has a single cause but rather results from a combination of predisposing factors.