What is the treatment for angular cheilitis?

Treatment of Angular Cheilitis

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

Understanding Angular Cheilitis

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

• Erythema, rhagades (fissures), ulcerations, and crusting at one or both lip commissures 1
• Two age peaks: during childhood and in older adults, becoming more frequent with aging 2
• Often has mixed etiology with both bacterial and fungal components 2, 1

Treatment Approach

First-Line Treatment

• Combination therapy with antifungal and corticosteroid: Apply 1% isoconazole nitrate with 0.1% diflucortolone valerate ointment to affected areas 1
  • The antifungal component addresses Candida infection
  • The corticosteroid reduces inflammation and discomfort

Alternative Topical Treatments

• For primarily fungal infection:

  • Nystatin oral suspension (100,000 units four times daily for 1 week) 3
  • Miconazole oral gel (5-10 mL held in mouth after food four times daily for 1 week) 3
  • Fluconazole (100 mg/day for 7-14 days) for more resistant cases 3

• For primarily bacterial infection:

  • Antiseptic oral rinse containing chlorhexidine twice daily 3
  • Topical antibacterial agents may be needed if bacterial culture confirms infection 1

Supportive Measures

• Emollient application: Apply white soft paraffin ointment to the lips every 2-4 hours 3
• Oral hygiene: Clean the mouth daily with warm saline mouthwashes 3
• Anti-inflammatory rinses: Use benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating 3

Addressing Underlying Causes

• Nutritional deficiencies:

  • Evaluate for iron deficiency, especially in women of childbearing age 4
  • Consider B-vitamin supplementation if deficiency is suspected 1, 5

• Mechanical factors:

  • Address ill-fitting dentures or loss of vertical dimension 1
  • Consider prosthetic devices for patients with excessive drooling 1

• Systemic conditions:

  • Evaluate for diabetes, immunosuppression, or other systemic diseases 6, 5
  • Manage underlying conditions appropriately 5

Treatment Duration and Follow-up

• Continue treatment until complete resolution of symptoms, typically 1-2 weeks 1
• If no improvement after 2 weeks, reevaluate for:
  • Correct diagnosis
  • Patient compliance
  • Need for oral antifungal therapy
  • Underlying systemic conditions 5

Common Pitfalls and Caveats

• Misdiagnosis: Angular cheilitis can be confused with herpes labialis, contact dermatitis, or actinic cheilitis 6
• Incomplete treatment: Treating only the fungal component without addressing inflammation may lead to treatment failure 1
• Overlooking underlying causes: Clinicians who only use antifungal agents may be treating symptoms rather than addressing predisposing factors 4
• Recurrence: Without addressing underlying causes (nutritional deficiencies, mechanical factors, systemic conditions), recurrence is common 5