What is the treatment for angular cheilitis (ulcers around the corners of the mouth)?

Treatment for Angular Cheilitis (Ulcers Around the Corners of the Mouth)

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, which addresses both the infectious and inflammatory components of this condition. 1

Understanding Angular Cheilitis

Angular cheilitis is characterized by:

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

Treatment Algorithm

First-Line Treatment

1. Topical antifungal-corticosteroid combination

   • 1% isoconazole nitrate with 0.1% diflucortolone valerate ointment applied 2-3 times daily 1
   • This combination addresses both fungal infection and inflammation simultaneously 1

2. Alternative topical treatments

   • Antifungal agents (miconazole, clotrimazole, nystatin) for fungal component 3
   • Topical antibiotics if bacterial infection is suspected 3
   • Topical corticosteroids to reduce inflammation 4

Supportive Measures

1. Oral hygiene and moisture control

   • Clean the mouth daily with warm saline mouthwashes 4
   • Apply white soft paraffin ointment to lips every 2 hours 4
   • Use antiseptic oral rinses twice daily (e.g., 0.2% chlorhexidine) 4

2. Pain management

   • Topical anesthetic preparations before meals 4
   • Mucoprotectant mouthwashes three times daily 4

Addressing Underlying Causes

1. Nutritional deficiencies

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

2. Mechanical factors

   • Evaluate and correct loss of vertical dimension in denture wearers 1
   • Consider anti-drooling prosthetic devices if excessive drooling is a factor 1

3. Systemic conditions

   • Evaluate for underlying systemic diseases that may manifest as angular cheilitis 6
   • Consider specialist referral for persistent cases (>2 weeks) 7

Special Considerations

1. For persistent cases

   • Biopsy may be necessary to rule out malignancy or other conditions 7
   • Consider photodynamic therapy for refractory cases 1

2. For recurrent cases

   • Investigate for systemic immune suppression 2
   • Consider maintenance therapy with topical antifungals 3

Common Pitfalls to Avoid

• Treating only the fungal component while ignoring bacterial infection or inflammation 1
• Overlooking iron deficiency as a predisposing factor, especially in women 5
• Failing to address mechanical factors such as ill-fitting dentures or loss of vertical dimension 1
• Relying solely on topical treatments without establishing a definitive diagnosis for persistent cases 7
• Not considering systemic conditions that may manifest as angular cheilitis 6

Follow-up Recommendations

• Improvement should be seen within 7-10 days of appropriate treatment 4
• If no improvement after 2 weeks of treatment, specialist referral is indicated 7
• Regular monitoring for recurrence, especially in patients with predisposing factors 2