What is the treatment for angular stomatitis?

Treatment of Angular Stomatitis

The first-line treatment for angular stomatitis is topical antifungal-corticosteroid combination therapy such as 1% isoconazole nitrate with 0.1% diflucortolone valerate ointment, applied 2-4 times daily until healing occurs. 1

Diagnosis and Etiology

Angular stomatitis (also called angular cheilitis) presents as:

• Thinning or fissuring at the corners of the mouth
• Erythema, ulcerations, and crusting of one or both lip commissures
• Often painful and uncomfortable for patients

The condition has a multifactorial etiology:

• Fungal infections (primarily Candida species)
• Bacterial infections (often Staphylococcus or Streptococcus)
• Nutritional deficiencies, particularly riboflavin (vitamin B2) 2, 3, 4
• Local factors such as moisture accumulation at lip corners

Treatment Algorithm

Step 1: Topical Therapy

• First-line treatment: Combination antifungal-corticosteroid ointment
  • 1% isoconazole nitrate with 0.1% diflucortolone valerate ointment applied 2-4 times daily 1
  • Alternative: Other topical antifungals (miconazole, clotrimazole) with corticosteroids
• For primarily bacterial infection: Topical antibiotics or antiseptics
  • Gentian violet topical application has shown efficacy 3
  • Topical antibiotics if bacterial culture confirms bacterial etiology

Step 2: Address Underlying Causes

• Nutritional supplementation if deficiency is suspected:
  • B-complex vitamins, particularly riboflavin (4-10 mg daily) 3, 4
  • Assessment for other vitamin deficiencies (B6, iron) that may coexist 3
• Oral hygiene measures as recommended by the American Dental Association 5:
  • Soft toothbrush and mild non-foaming toothpaste
  • Saline solution rinses 4-6 times daily
  • Alcohol-free mouthwash

Step 3: Management of Persistent Cases

• For refractory cases:
  • Rule out systemic conditions (diabetes, immunosuppression)
  • Consider oral antifungals if extensive fungal involvement
  • Evaluate for denture-related issues or occlusal problems
  • Consider biopsy if lesion persists beyond 2 weeks despite treatment 5

Special Considerations

Nutritional Deficiency

• High prevalence of riboflavin deficiency has been associated with angular stomatitis 2, 3, 4
• Studies show that while glossitis responds well to B-vitamin supplementation, angular stomatitis often requires additional topical treatment 3
• Consider nutritional assessment in recurrent or persistent cases

Prevention Strategies

• Maintain good oral hygiene
• Address mechanical factors (ill-fitting dentures, deep vertical dimension)
• Avoid licking lips and mouth corners
• Apply petroleum jelly to lip corners in prone individuals
• Dietary modifications to ensure adequate B-vitamin intake

Monitoring and Follow-up

• Improvement should be seen within 7-14 days of appropriate treatment
• Any lesion persisting beyond 2 weeks requires further investigation to rule out malignancy or systemic disease 5
• Regular follow-up every 3-6 months for persistent or recurrent cases 5

Common Pitfalls

1. Treating only the fungal component without addressing bacterial co-infection or underlying nutritional deficiencies
2. Overlooking systemic causes of persistent angular stomatitis
3. Prolonged use of topical corticosteroids without antifungal coverage, which may worsen fungal infection
4. Failure to address mechanical factors such as ill-fitting dentures or deep facial folds in older patients