What are the causes of angular cheilosis in older adults?

Causes of Angular Cheilosis in Older Adults

Angular cheilitis in older adults is primarily a mixed infectious condition caused by Candida species (typically Candida albicans) and/or Staphylococcus aureus, though nutritional deficiencies—particularly riboflavin, iron, pyridoxine, and folate—can be important predisposing factors that must be evaluated. 1, 2, 3

Primary Infectious Etiology

The disease has a predominantly mixed infectious etiology with bacterial and fungal components. 3

• Candida albicans is the most common fungal pathogen, with 84% of long-term care facility residents colonized with yeast 1
• Staphylococcus aureus frequently co-exists with Candida in angular cheilitis lesions 4
• Mucocutaneous candidiasis results from overgrowth of endogenous resident fungi in moist macerated skin, particularly in association with antimicrobial and corticosteroid use 1
• Angular cheilitis represents one clinical pattern of oral candidiasis, characterized by inflammation and cracking at the corners of the mouth 5

Nutritional Deficiency as Predisposing Factor

While infection is the immediate cause, nutritional deficiencies act as critical predisposing factors, especially in older adults:

Riboflavin (Vitamin B2) Deficiency

• Riboflavin deficiency is the primary nutritional cause of angular cheilitis 2
• Classically presents with angular cheilitis, glossitis, photophobia, and corneal vascularization 2

Iron Deficiency

• Iron deficiency is an overlooked predisposing factor that should be considered in the differential diagnosis, particularly in women of childbearing age but also relevant in older adults 2, 6
• Clinicians treating only with antifungals may address symptoms without correcting the underlying predisposing cause 6

Pyridoxine (Vitamin B6) Deficiency

• Causes angular stomatitis with seborrheic dermatitis, cheilosis, glossitis, microcytic anemia, and neurological symptoms 2

Folate Deficiency

• Produces angular stomatitis, oral ulcers, glossitis, megaloblastic anemia, and neuropsychiatric manifestations 2
• Always assess for cobalamin (B12) deficiency simultaneously to avoid masking B12 deficiency with folate supplementation alone 2

Clinical Algorithm for Identifying Etiology

When to Suspect Nutritional Deficiency:

Consider nutritional causes when angular cheilitis occurs bilaterally with associated findings: 2

• Glossitis or other oral mucosal changes
• Anemia (microcytic or megaloblastic)
• Poor dietary intake, malabsorption, alcoholism, chronic kidney disease
• Medications interfering with vitamin metabolism
• Critical illness

Risk Factors for Infectious Etiology in Older Adults:

• Denture use (creates moist environment) 5
• Diabetes mellitus 5
• Immunosuppression 5
• Use of antimicrobials or corticosteroids 1
• Poor oral hygiene 7

Diagnostic Workup

For suspected nutritional deficiency: 2

• Measure serum riboflavin, pyridoxine, folate, vitamin B12, and complete iron studies
• Normal plasma pyridoxal 5-phosphate: 20-200 nmol/L
• Serum folate should be ≥10 nmol/L; RBC folate ≥340 nmol/L

For infectious confirmation: 1

• Microscopic examination of scrapings with 10% potassium hydroxide can confirm Candida species or dermatophytes
• If candidal infection fails empirical treatment, perform cultures and yeast speciation

Critical Pitfalls to Avoid

• Do not assume angular cheilitis is purely nutritional—it most commonly has a mixed infectious etiology requiring antimicrobial treatment 2, 3
• Do not treat with antifungals alone without considering iron or vitamin deficiencies as predisposing factors 6
• Lesions persisting beyond 2 weeks despite appropriate treatment warrant biopsy to exclude dysplasia or malignancy 2
• In patients with macrocytic anemia, always measure both folate and B12 simultaneously to avoid masking B12 deficiency 2
• Recognize that 80% of patients experience recurrence after successful antimicrobial treatment, indicating the need for longer-term management perspective 4

Treatment Approach

First-line treatment typically requires combination therapy: 2

• Combination antifungal and corticosteroid therapy for the infectious component
• For confirmed nutritional deficiency: oral supplementation with the deficient vitamin (riboflavin, pyridoxine 50-100 mg daily for 1-2 weeks, or folate as indicated) 2