Can Vitamin B12 (B12) deficiency cause cheilitis?

Can B12 Deficiency Cause Cheilitis?

Yes, vitamin B12 deficiency can cause cheilitis, but it is not the most common cause—riboflavin (vitamin B2) deficiency is more strongly associated with oral-buccal lesions including cheilosis and angular stomatitis. 1

Understanding the Relationship Between B Vitamins and Cheilitis

While the question focuses on B12, the evidence shows that riboflavin (B2) deficiency is the primary B vitamin deficiency that manifests with oral-buccal lesions including cheilosis, glossitis, and angular stomatitis 1. Riboflavin deficiency is frequently associated with other B vitamin deficiencies including pyridoxine (B6), folate, and niacin, which can present with overlapping symptoms 1.

B12 Deficiency and Oral Manifestations

B12 deficiency does cause oral manifestations, though these are typically described differently than classic "cheilitis":

• Glossitis (tongue inflammation) is the most common oral manifestation of B12 deficiency 2
• Painful erythema areas, burning sensation, dysgeusia, lingual paresthesia, and itching can occur 3
• Papillary atrophy of the tongue is characteristic 3

Clinical Context and Diagnostic Approach

The etiology of cheilitis is multifactorial, and B12 deficiency may be present as part of a broader nutritional deficiency pattern 4, 5. In a cross-sectional study of 130 cheilitis patients, vitamin B9, B12, and iron serum values were mostly within normal reference ranges, suggesting these are not the primary drivers in most cases 5.

Cheilitis can appear as an isolated condition or as part of systemic diseases including anemia due to vitamin B12 or iron deficiency 4. However, the disease more commonly has mixed bacterial and fungal components, particularly in angular cheilitis 6.

When to Consider B12 Deficiency in Cheilitis Patients

High-Risk Populations Requiring B12 Testing

Test for B12 deficiency when cheilitis occurs with:

• Age >75 years (18.1% have metabolic deficiency; 25% of those ≥85 years have low B12) 7
• Metformin use >4 months 7, 2
• PPI or H2 blocker use >12 months 7, 2
• Post-bariatric surgery patients (reduced intrinsic factor and gastric acid) 1, 2
• Vegan or vegetarian diets without supplementation 2
• Autoimmune conditions (thyroid disease, type 1 diabetes, Sjögren syndrome) 7, 2

Associated Symptoms That Strengthen B12 Deficiency Diagnosis

Look for these accompanying features:

• Hematologic findings: anemia, macrocytosis on complete blood count 7, 2
• Neurological symptoms: peripheral neuropathy, balance issues, cognitive difficulties 7, 2
• Other oral manifestations: glossitis with papillary atrophy, burning tongue 2, 3
• Visual problems: blurred vision related to optic nerve dysfunction 7, 2

Diagnostic Algorithm for Cheilitis with Suspected B12 Deficiency

Initial Testing

1. Start with serum total vitamin B12 (costs ~£2, rapid turnaround) 7

   • <180 pg/mL: Confirms deficiency—treat immediately 7
   • 180-350 pg/mL: Indeterminate—proceed to MMA testing 7
   • >350 pg/mL: Deficiency unlikely, but consider functional markers if high clinical suspicion 7

2. For indeterminate results, measure methylmalonic acid (MMA) 7

   • MMA >271 nmol/L confirms functional B12 deficiency (98.4% sensitivity) 7
   • This detects an additional 5-10% of patients with deficiency who have low-normal B12 levels 7

Critical Pitfall to Avoid

Up to 50% of patients with "normal" serum B12 have metabolic deficiency when measured by MMA 7. This is especially important in elderly patients (>60 years), where metabolic deficiency is common despite normal serum levels 7.

Treatment Approach

When B12 Deficiency is Confirmed

Treat B12 deficiency immediately before initiating folic acid supplementation to avoid masking the deficiency and precipitating subacute combined degeneration of the spinal cord 1, 2.

Without Neurological Involvement

• Hydroxocobalamin 1 mg intramuscularly three times a week for 2 weeks 2
• Maintenance: 1 mg intramuscularly every 2-3 months for life 2

With Neurological Involvement

• Hydroxocobalamin 1 mg intramuscularly on alternate days until no further improvement 2
• Maintenance: 1 mg intramuscularly every 2 months 2

Oral Supplementation Alternative

• Oral B12 1000-2000 μg daily is as effective as intramuscular administration for most patients (without severe neurologic manifestations or confirmed malabsorption) 7

Consider Riboflavin Deficiency Concurrently

Since riboflavin deficiency is more directly associated with cheilosis and angular stomatitis 1, and riboflavin deficiency is frequently associated with other B vitamin deficiencies 1:

• Recommended riboflavin dose: 3.6-5 mg daily 1
• Main sources include enriched grains, meats, dairy products, fatty fish, eggs, and dark-green vegetables 1

Special Population Considerations

Post-bariatric surgery patients require lifelong supplementation: 1000 mcg/day oral or 1000 mcg/month IM indefinitely 7. Deficiencies can occur even when serum concentrations are 300 pmol/L (~406 pg/mL) in this population 7.