How is Angular Cheilitis managed and treated?

Management and Treatment of Angular Cheilitis

Angular cheilitis should be treated with a combination of antifungal and anti-inflammatory agents, while addressing underlying causes such as nutritional deficiencies, mechanical factors, or systemic conditions. 1

Etiology and Diagnosis

• Angular cheilitis (AC) is characterized by erythema, maceration, ulceration, and crusting at the corners of the mouth, with two age peaks: childhood and older adults 2, 3
• Common etiological factors include:
  • Infectious causes (fungal and bacterial components) 2
  • Irritants (climatic, mechanical, caustic agents) 4
  • Allergic contact reactions 4
  • Nutritional deficiencies, particularly iron deficiency 5
  • Systemic conditions (immune suppression, atopic dermatitis) 4

Treatment Algorithm

First-Line Treatment

• Topical combination therapy with antifungal and corticosteroid agents is the most effective first-line treatment for angular cheilitis 1
  • 1% isoconazole nitrate (antifungal) with 0.1% diflucortolone valerate (corticosteroid) ointment is particularly effective due to:
    • Broad spectrum activity against dermatophytes and bacteria
    • Anti-inflammatory properties to reduce discomfort and inflammation

Treatment Based on Specific Etiology

• For predominantly fungal infections:

  • Topical antifungal agents such as nystatin oral suspension 100,000 units four times daily for 1 week 6
  • Miconazole oral gel applied to affected areas 4 times daily for 1 week 6

• For inflammatory component:

  • Topical corticosteroid preparations:
    • Betamethasone sodium phosphate solution 6
    • Potent topical corticosteroid ointment once daily to involved, non-eroded surfaces 6

• For bacterial infections:

  • Antiseptic oral rinses containing chlorhexidine digluconate 0.2% twice daily 6
  • Hydrogen peroxide solutions (1.5%) as mouth rinses 6

Supportive Measures

• Apply white soft paraffin ointment to affected areas every 2-4 hours throughout the day 6
• Maintain good oral hygiene with gentle cleaning using warm saline mouthwashes 6
• Use silicone-based dressings (e.g., Mepitel) on eroded areas to reduce pain and prevent adhesions 6

Management of Underlying Causes

• Nutritional deficiencies:

  • Screen for and correct iron deficiency, particularly in women of childbearing age 5
  • Consider B-vitamin supplementation if deficiency is suspected 1

• Mechanical factors:

  • Address loss of vertical dimension in edentulous patients 1
  • Consider prosthetic interventions for drooling issues 1

• Systemic conditions:

  • More aggressive treatment approaches for immunocompromised patients 7
  • Evaluate for and treat underlying systemic diseases (lichen planus, lupus, atopic dermatitis) 4

Special Considerations

• For persistent or recurrent cases, consider biopsy to rule out more serious conditions, especially in chronic actinic cheilitis which has malignant potential 4
• Photodynamic therapy may be considered for cases of actinic cheilitis that don't respond to conventional treatments 7
• For allergic contact cheilitis, detailed history and patch testing may be necessary to identify and eliminate causative agents 4

Treatment Pitfalls to Avoid

• Treating only the symptoms without addressing underlying causes may lead to recurrence 5
• Overuse of topical corticosteroids can lead to skin atrophy and other adverse effects 1
• Failure to recognize iron deficiency as a predisposing factor, especially in women of childbearing age 5
• Not distinguishing between different types of cheilitis, which require different treatment approaches 4