Angular Cheilitis: Associated Conditions
Angular cheilitis (not "chelates") is primarily associated with nutritional deficiencies (iron, B vitamins, folate), oral candidiasis, ill-fitting dentures, and conditions causing immunosuppression or chronic anemia.
Iron Deficiency and Anemia-Related Conditions
Angular cheilitis commonly occurs in patients with iron deficiency anemia, which may result from:
- Chronic transfusion-dependent anemias including β-thalassemia major and sickle cell disease, where patients paradoxically develop iron deficiency in tissues despite systemic iron overload 1, 2
- Myelodysplastic syndromes (MDS) with chronic anemia, particularly lower-risk MDS patients who may have nutritional deficiencies 1
- Hemochromatosis patients undergoing aggressive phlebotomy, where overly aggressive iron removal can lead to functional iron deficiency in mucosal tissues 1, 3
Nutritional Deficiency States
Angular cheilitis serves as a clinical marker for:
- Vitamin B complex deficiencies (particularly B2/riboflavin, B3/niacin, B6/pyridoxine, and B12/cobalamin)
- Folate deficiency, commonly seen in patients with chronic hemolytic anemias or malabsorption
- Zinc deficiency, which can occur as a side effect of iron chelation therapy with deferiprone 1
- Combined micronutrient deficiencies in patients with malabsorption syndromes
Infectious and Inflammatory Conditions
- Oral candidiasis (Candida albicans infection), particularly in immunocompromised patients
- Bacterial superinfection (Staphylococcus aureus, Streptococcus species)
- Mixed fungal-bacterial infections in the perioral area
Conditions Causing Chronic Moisture and Maceration
- Ill-fitting dentures causing saliva pooling at mouth corners
- Drooling from neurological conditions or poor oral motor control
- Deep nasolabial folds in elderly patients
- Chronic lip licking or mouth breathing
Immunocompromised States
Angular cheilitis occurs more frequently in:
- Patients on immunosuppressive therapy, including those receiving treatment for MDS or post-transplant 1
- HIV/AIDS patients with compromised immune function
- Diabetes mellitus with poor glycemic control
- Patients receiving chemotherapy for hematologic malignancies
Hematologic Conditions Requiring Monitoring
Patients with the following conditions warrant evaluation for angular cheilitis as a sign of treatment complications:
- Thalassemia major patients on iron chelation therapy who may develop zinc or other micronutrient deficiencies from deferiprone use 1, 2
- MDS patients with neutropenia who are at increased risk of oral infections 1
- Hemochromatosis patients undergoing phlebotomy where overly aggressive treatment may cause functional iron deficiency 3
Clinical Pitfall to Avoid
Do not assume angular cheilitis in iron-overloaded patients means they need more iron. In patients with transfusional iron overload (thalassemia, MDS), angular cheilitis may indicate zinc deficiency from chelation therapy rather than iron deficiency 1. Check zinc levels and consider supplementation while continuing appropriate iron chelation 1.