What is the treatment for retinoid-induced angular cheilitis?

Treatment for Retinoid-Induced Angular Cheilitis

Topical tacrolimus 0.1% ointment applied twice daily is the most effective treatment for retinoid-induced angular cheilitis, showing faster and more significant resolution compared to petroleum jelly. 1

Understanding Retinoid-Induced Angular Cheilitis

Angular cheilitis (AC) is a common side effect of systemic retinoid therapy, characterized by:

• Erythema, scaling, fissuring, and crusting at the corners of the mouth
• Pain and discomfort during mouth opening
• Dose-dependent relationship with retinoid use

Retinoids (isotretinoin, acitretin) cause mucocutaneous adverse effects in nearly all patients, with cheilitis being the most frequent manifestation 1, 2.

Treatment Algorithm

First-Line Treatment

1. Topical tacrolimus 0.1% ointment:
   • Apply twice daily to affected areas
   • Provides faster resolution (84.6% of patients show improvement within 1 week)
   • Lower relapse rate compared to alternatives 1

Alternative Treatments

1. Combination antifungal/corticosteroid preparations:

   • 1% isoconazole nitrate with 0.1% diflucortolone valerate ointment
   • Addresses both inflammatory and potential fungal components 3

2. Petroleum jelly (white soft petrolatum):

   • Apply twice daily
   • Less effective than tacrolimus (53.8% resolution within 1 week)
   • Higher relapse rate 1

Adjunctive Measures

• Gentle cleansing of the affected area
• Avoidance of irritants that may worsen the condition
• Protection of fissures using petroleum jelly to prevent secondary infection 4

Special Considerations

Addressing Underlying Causes

• Dose adjustment of retinoid therapy if cheilitis is severe and interfering with quality of life
• Continue retinoid therapy if clinically necessary, as cheilitis can be managed with appropriate topical treatment

Monitoring Treatment Response

• Use the Isotretinoin Cheilitis Grading Scale (ICGS) to objectively assess:
  • Erythema
  • Scale/crust
  • Fissures
  • Inflammation of the commissures 2

When to Consider Additional Evaluation

• If cheilitis persists despite appropriate treatment
• If signs of secondary bacterial or fungal infection develop (increased erythema, purulence)
• If symptoms worsen rather than improve with treatment

Potential Pitfalls

• Misdiagnosis: Ensure the angular cheilitis is truly retinoid-induced rather than due to other causes (nutritional deficiencies, candidal infection)
• Inadequate treatment duration: Continue treatment until complete resolution
• Overlooking secondary infection: Consider bacterial or fungal superinfection if not responding to initial therapy 5
• Prolonged use of potent topical corticosteroids: Can potentially worsen the condition over time 6

By following this treatment approach, most cases of retinoid-induced angular cheilitis can be effectively managed while allowing patients to continue their necessary retinoid therapy.