What is the management of angular cheilitis?

Management of Angular Cheilitis

The first-line treatment for angular cheilitis is combination therapy with antifungal and corticosteroid agents, addressing both fungal infection and inflammation simultaneously. 1

Etiology and Assessment

• Angular cheilitis presents as erythema, fissures, ulcerations, and crusting at the corners of the mouth, causing pain and discomfort 2, 3
• Common etiological factors include:
  • Fungal infections (primarily Candida albicans) 4, 1
  • Bacterial infections 1, 2
  • Local irritants (climatic, mechanical, caustic agents) 5, 6
  • Nutritional deficiencies, particularly riboflavin and iron 4, 7
  • Mechanical factors (ill-fitting dentures, loss of vertical dimension) 1
  • Systemic conditions (diabetes, immunosuppression) 1, 5

Treatment Algorithm

1. First-Line Treatment

• Apply combination antifungal-corticosteroid preparation to affected areas 1-3 times daily for 7-14 days 1, 3
  • The antifungal component addresses Candida infection
  • The corticosteroid component reduces inflammation and discomfort

2. Alternative Topical Treatments Based on Predominant Cause

• For primarily fungal infection:

  • Nystatin oral suspension (100,000 units four times daily for 1 week) 1
  • Miconazole oral gel (5-10 mL held in mouth after food four times daily for 1 week) 1
  • For resistant cases: Fluconazole (100 mg/day for 7-14 days) 4, 1

• For primarily bacterial infection:

  • Antiseptic oral rinse containing chlorhexidine twice daily 1
  • Bacitracin ointment applied 1-3 times daily (for adults and children over 2 years) 8

3. Supportive Measures

• Apply emollient (white soft paraffin ointment) to the lips every 2-4 hours 1
• Maintain oral hygiene with warm saline mouthwashes daily 1
• Use anti-inflammatory rinses with benzydamine hydrochloride every 3 hours, particularly before eating 1

4. Address Underlying Causes

• Correct mechanical factors:

  • Repair or replace ill-fitting dentures 1
  • Consider occlusal vertical dimension restoration if appropriate 1

• Treat nutritional deficiencies:

  • Riboflavin supplementation (1-1.6 mg/day) for deficiency 4
  • Iron supplementation if iron deficiency is identified 7

• Manage systemic conditions:

  • Evaluate and treat diabetes or immunosuppression 1, 5
  • Review medications that may contribute to the condition 1
  • Address habits like lip licking or mouth breathing 1

Special Considerations

• Immunocompromised patients may require more aggressive and prolonged therapy 4, 1
• If no improvement after 2 weeks, reevaluate for correct diagnosis and patient compliance 1
• Consider biopsy to rule out more serious conditions if lesions persist despite appropriate treatment 5

Common Pitfalls to Avoid

• Treating only the symptoms without addressing underlying causes 7
• Failing to distinguish angular cheilitis from other conditions like actinic cheilitis (a premalignant condition) 1, 5
• Overlooking nutritional deficiencies, particularly iron deficiency in women of childbearing age 7
• Not evaluating for systemic conditions that may predispose to angular cheilitis 1, 5
• Using antifungal agents alone when combination therapy is more effective 1, 3