What is the treatment for angular cheilitis?

Treatment of Angular Cheilitis

The most effective first-line treatment for angular cheilitis is a combination antifungal-corticosteroid preparation such as 1% isoconazole nitrate with 0.1% diflucortolone valerate ointment applied to the affected areas 2-3 times daily until healing is complete. 1

Understanding Angular Cheilitis

Angular cheilitis is an inflammatory condition affecting the corners of the mouth, characterized by:

• Erythema (redness)
• Rhagades (fissures)
• Ulcerations
• Crusting at one or both lip commissures

It has a mixed etiology, typically involving:

• Fungal infection (primarily Candida species)
• Bacterial infection (often Staphylococcus aureus)
• Local irritation factors
• Possible underlying systemic conditions

Treatment Algorithm

Step 1: Identify and Address Underlying Causes

• Moisture-related: Correct excessive moisture at corners of mouth
• Mechanical factors: Address ill-fitting dentures or loss of vertical dimension
• Nutritional deficiencies: Evaluate for vitamin B, iron, or folate deficiencies
• Systemic conditions: Consider diabetes, immunosuppression, or other conditions

Step 2: First-Line Treatment

• Combination therapy: Apply antifungal-corticosteroid preparation to affected areas 2-3 times daily 1
  • 1% isoconazole nitrate with 0.1% diflucortolone valerate ointment is highly effective due to:
    • Broad spectrum activity against dermatophytes and bacteria
    • Anti-inflammatory properties to reduce discomfort

Step 3: Alternative Topical Treatments

• For primarily fungal infections: Nystatin topical powder for very moist lesions, applied 2-3 times daily until healing is complete 2
• For inflammatory component: Topical corticosteroids such as clobetasol 0.05%, betamethasone, or fluticasone propionate 3
• For pain management: Topical anesthetics like lidocaine viscous 2% solution (15 mL swished and expectorated every 3 hours as needed, maximum 8 doses/24 hours) 3

Step 4: Adjunctive Measures

• Barrier preparations: Gengigel or Gelclair for pain control 3
• Oral hygiene: Use soft toothbrush and mild non-foaming toothpaste 3
• Dietary modifications: Avoid spicy, acidic, or rough foods 3
• Hydration: Maintain adequate fluid intake 3

Special Considerations

For Denture Wearers

• Clean gums thoroughly and maintain proper denture hygiene
• Remove dentures before oral care and at night
• Consider adhesives to improve fit
• For fungal infections extending to feet, dust antifungal powder on feet and in footwear 2

For Severe or Refractory Cases

• Consider tacrolimus 0.1% ointment applied twice daily 3
• Intralesional triamcinolone acetonide injections may reduce time to clinical remission 3
• Topical ciclosporin mouthwash (though expensive and unpleasant tasting) 3

Prevention Strategies

• Maintain good oral hygiene
• Apply medicated lip balm regularly
• Stay hydrated to keep oral tissues moist
• Avoid known triggers (hard, acidic, spicy foods; toothpastes with sodium lauryl sulfate; alcohol)
• Regular dental check-ups, especially for denture wearers

Monitoring and Follow-up

• Monitor for symptom improvement within 7-14 days
• If no improvement, reassess diagnosis and consider alternative treatments
• For persistent cases, follow up every 3-6 months to assess for systemic disease

Angular cheilitis treatment should target both the infectious components and inflammatory aspects of the condition while addressing any underlying contributing factors to prevent recurrence.