Treatment of Angular Stomatitis
Apply topical antifungal agents (nystatin oral suspension or miconazole oral gel) to the affected corners of the mouth as first-line treatment for angular stomatitis. 1
Initial Treatment Approach
- Start with topical antifungal therapy as the primary intervention, specifically nystatin oral suspension or miconazole oral gel applied directly to the oral commissures 1
- Maintain good oral hygiene using non-alcoholic mouthwashes to prevent secondary bacterial colonization 1
- Use sodium bicarbonate rinses (1 teaspoon table salt mixed with three-quarter teaspoon baking soda in 500 mL water) 4-6 times daily to maintain oral pH and reduce microbial load 1
Evaluation of Contributing Factors
- Assess and adjust dental appliances (dentures, braces, retainers) that may be causing moisture accumulation and maceration at the oral commissures 1
- Evaluate for oral dryness (xerostomia) and consider salivary substitutes or sialogogues if contributing to the condition 1
- Screen for nutritional deficiencies, particularly iron deficiency (especially in women of childbearing age), as well as B-vitamin deficiencies (riboflavin, pyridoxine), which are often overlooked predisposing factors 2, 3
Treatment Escalation for Moderate to Severe Cases
- Consider combination antifungal and antibacterial therapy if secondary bacterial infection is suspected, as angular stomatitis has a complex etiology often associated with infection 1, 3
- Add antiseptic oral rinses such as 0.2% chlorhexidine digluconate mouthwash twice daily for moderate to severe cases 1
- Topical corticosteroids may be considered if significant inflammation is present, but only after ensuring adequate antimicrobial coverage 1
Alternative Treatment Options
Recent evidence suggests that 1% isoconazole nitrate combined with 0.1% diflucortolone valerate ointment may be the most consistent treatment due to the broad spectrum of isoconazole against dermatophytes and bacteria, plus the anti-inflammatory properties of diflucortolone 4
Important Clinical Pitfalls
- Do not assume antifungal therapy alone will resolve the condition without addressing underlying predisposing factors such as iron deficiency, which may be the primary cause rather than just treating symptoms 2
- Angular stomatitis has a more complex etiology than glossitis and may not respond to B-vitamin supplementation alone, unlike glossitis which responds to riboflavin and pyridoxine 3
- Ensure dental prosthetics fit properly, as ill-fitting dentures are a common mechanical cause of persistent angular stomatitis 1