What is the treatment for angular cheilitis?

Treatment of Angular Cheilitis

Start with combination antifungal-corticosteroid therapy as first-line treatment, which addresses both the Candida infection and inflammatory components simultaneously. 1, 2

First-Line Treatment Approach

Apply a topical combination of antifungal and corticosteroid to the affected lip commissures. 1, 2 The antifungal component targets Candida species (the most common infectious agent), while the corticosteroid reduces inflammation and provides symptomatic relief. 1 Based on clinical experience, 1% isoconazole nitrate with 0.1% diflucortolone valerate ointment is particularly effective due to its broad antimicrobial spectrum covering dermatophytes and bacteria in addition to fungi. 3

Alternative Topical Regimens

If combination therapy is unavailable or when infection type is clearly identified:

For Predominantly Fungal Infection:

• Nystatin oral suspension (100,000 units four times daily for 1 week) applied to the corners of the mouth 1, 2
• Miconazole oral gel (5-10 mL held in mouth after food four times daily for 1 week) 1, 2
• Fluconazole (100 mg/day for 7-14 days) for resistant cases 1, 2

For Predominantly Bacterial Infection:

• Chlorhexidine-containing antiseptic oral rinse twice daily 1, 2

Essential Supportive Measures

These adjunctive treatments accelerate healing and prevent recurrence:

• White soft paraffin ointment applied to lips every 2-4 hours to maintain moisture barrier and prevent cracking 1, 2
• Warm saline mouthwashes daily for oral hygiene 1, 2
• Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating, for pain relief 1, 2

Critical caveat: Avoid chronic use of petroleum-based products on lips as they promote mucosal dehydration and create an occlusive environment that increases secondary infection risk. 1

Addressing Underlying Mechanical and Systemic Factors

Treatment will fail without correcting predisposing conditions:

Mechanical Factors to Evaluate:

• Ill-fitting dentures requiring adjustment or replacement 1, 2
• Loss of vertical dimension necessitating occlusal restoration 1, 2
• Habits including lip licking or mouth breathing that must be addressed 1, 2

Systemic Conditions to Screen:

• Diabetes mellitus or other causes of immunosuppression 1, 2
• Iron deficiency, particularly in women of childbearing age, which is an often-overlooked predisposing factor 4
• B-vitamin deficiencies 3
• Medications that may contribute (review and adjust if possible) 1, 2

Treatment Duration and Reassessment

• Reassess at 2 weeks if no improvement occurs 1, 2
• At reassessment, verify correct diagnosis and evaluate patient compliance 1, 2
• Immunocompromised patients require more aggressive and prolonged therapy from the outset 1, 2

Special Clinical Situations

For Severe Pain:

• Viscous lidocaine 2% (15 mL per application) for topical anesthesia 2
• "Magic Mouthwash" (equal parts diphenhydramine, antacid, and viscous lidocaine) for severe cases 2

For Severe Inflammation:

• Clobetasol propionate 0.05% mixed with Orabase applied directly to affected areas daily 2

Important Differential Diagnosis:

• Distinguish angular cheilitis from actinic cheilitis, a premalignant condition requiring photodynamic therapy rather than antifungal treatment 1, 2

Common Pitfalls to Avoid

• Do not use alcohol-containing mouthwashes, which cause additional pain and irritation 2
• Do not treat with antifungals alone without addressing mechanical factors—this treats symptoms but not the underlying cause 4
• Do not overlook nutritional deficiencies, particularly iron and B-vitamins, especially in at-risk populations 3, 4