What is the treatment for angular cheilitis?

Treatment of Angular Cheilitis

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

Etiology and Diagnosis

Angular cheilitis presents as erythema, fissuring, ulceration, and crusting at the corners of the mouth. It has a mixed etiology that typically includes:

• Infectious causes: Primarily Candida albicans, but may also involve bacterial pathogens 2, 3
• Local factors: Moisture accumulation in lip corners, drooling, deep skin folds 4
• Systemic factors: Nutritional deficiencies, immunosuppression (including HIV) 5

Treatment Algorithm

First-Line Treatment

1. Combined antifungal and anti-inflammatory therapy:

   • Apply 1% isoconazole nitrate and 0.1% diflucortolone valerate ointment to affected areas 2-3 times daily 1
   • Alternative: Nystatin oral suspension or miconazole oral gel for confirmed candidal infection 6

2. For HIV-infected patients with candidal angular cheilitis:

   • Topical antifungal treatment with clotrimazole troches (10 mg) dissolved 5 times daily or miconazole mucoadhesive tablets applied to affected areas 2
   • For refractory cases, fluconazole 100-200 mg daily for 7-14 days 2

Supportive Measures

1. Oral hygiene:

   • Gentle cleaning with soft toothbrush and mild, non-foaming toothpaste 6
   • Rinse with alcohol-free antiseptic mouthwash (0.2% chlorhexidine) 2-4 times daily 6

2. Topical corticosteroids for inflammation:

   • Betamethasone sodium phosphate 0.5 mg dissolved in 10 mL water as a rinse-and-spit solution 1-4 times daily 2
   • Clobetasol 0.05% ointment mixed in 50% Orabase applied to localized lesions twice daily 2

3. Barrier preparations:

   • Apply sucralfate suspension to create a protective coating over ulcers 6
   • Gengigel mouth rinse or Gelclair for pain control 2

Special Considerations

For Immunocompromised Patients

• More aggressive antifungal therapy may be required 2
• Consider examination of partners in HIV-infected patients as transmission of resistant isolates has been documented 2
• Monitor for development of azole resistance, particularly in patients with advanced immunosuppression 2

For Nutritional Deficiency-Related Cases

• Assess and correct nutritional deficiencies, particularly B vitamins 5
• Consider systemic supplementation if deficiencies are confirmed 1

For Denture Wearers

• Remove dentures before performing oral care 6
• Consider deferring wearing dental prostheses until tissues heal 6
• Soak dentures in antimicrobial solution overnight 6

Pain Management

• Topical 2.5% lidocaine ointment applied cautiously for pain relief 6
• Benzydamine hydrochloride oral rinse or spray every 2-4 hours, particularly before eating 6
• For severe pain, consider systemic analgesics following the WHO pain management ladder 6

Monitoring and Follow-up

• Assess pain at least once daily using an appropriate pain scale 6
• Follow up within 3-5 days if symptoms are not improving 6
• For persistent cases, consider underlying systemic conditions and refer appropriately 5

Angular cheilitis often resolves within 1-2 weeks with appropriate treatment, but may recur if underlying causes are not addressed. Treatment should target both infectious components and contributing factors to achieve complete resolution.