What is angular cheilitis (cheilosis) and what are the first‑line management strategies?

Angular Cheilitis: Definition and First-Line Management

Angular cheilitis (cheilosis) is inflammation at the corners of the mouth characterized by erythema, maceration, ulceration, and crusting, and first-line treatment is combination topical therapy with an antifungal plus corticosteroid applied 2-3 times daily for 1-2 weeks. 1

What is Angular Cheilitis?

Angular cheilitis is a common inflammatory condition affecting the oral commissures (corners of the mouth) with mixed infectious etiology 2, 3. The condition presents with:

• Erythema and moist maceration at the mouth corners 2
• Ulceration and crusting 2
• Mixed bacterial and fungal components, primarily Candida albicans 4, 3

The disease has two age peaks—childhood and adulthood—becoming more frequent with aging 3.

First-Line Management Strategy

Primary Treatment: Combination Therapy

Use topical combination of hydrocortisone 1% with an antifungal agent (miconazole 2% or clotrimazole 1%), applied 2-3 times daily for 1-2 weeks. 1

The rationale for combination therapy:

• The antifungal component addresses Candida infection 1
• The corticosteroid component reduces inflammation and discomfort 1

Specific Product Options

Choose based on lesion characteristics 1:

• Daktacort (hydrocortisone 1% + miconazole 2%): Available as cream or ointment 1
• Canesten HC (hydrocortisone 1% + clotrimazole 1%): Available as cream or ointment 1
• Use cream if lesion is weeping or moist; use ointment if skin is dry 1

Alternative for Suspected Bacterial Superinfection

Trimovate (clobetasone 0.05% + oxytetracycline 3% + nystatin 100,000 units/g) is a moderate-potency alternative when bacterial superinfection is suspected 1.

Supportive Measures (Adjunctive to Primary Treatment)

Implement these alongside topical therapy 1:

• White soft paraffin ointment to lips every 2-4 hours as an emollient 1
• Warm saline mouthwashes daily for oral hygiene 1
• Benzydamine hydrochloride rinse or spray every 3 hours, particularly before eating, for anti-inflammatory effect 1

Critical pitfall: 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.

Alternative Topical Treatments (If Combination Therapy Unavailable)

For Primarily Fungal Infection

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

For Primarily Bacterial Infection

• Antiseptic oral rinse containing chlorhexidine twice daily 1

Addressing Underlying Causes

Evaluate and correct mechanical factors 1:

• Ill-fitting dentures or loss of vertical dimension
• Consider occlusal vertical dimension restoration in appropriate cases

Screen for systemic conditions 1:

• Diabetes or immunosuppression
• Review medications that may contribute
• Address habits like lip licking or mouth breathing

Consider nutritional deficiencies when angular cheilitis occurs bilaterally with associated findings like glossitis, other oral mucosal changes, or anemia 5:

• Riboflavin deficiency (primary nutritional cause) 5
• Iron deficiency 4, 5
• Pyridoxine, folate, and vitamin B12 deficiencies 5

Measure serum levels of riboflavin, pyridoxine, folate, vitamin B12, and iron studies in suspected nutritional deficiency 5.

Treatment Duration and Follow-Up

If no improvement after 2 weeks, reevaluate for correct diagnosis and patient compliance 1, 4.

Lesions persisting beyond 2 weeks despite appropriate treatment warrant biopsy to exclude dysplasia or malignancy 5.

Special Populations: Immunocompromised Patients

Immunocompromised patients require more aggressive and prolonged therapy 1, 4:

• Consider systemic fluconazole (100 mg/day for 7-14 days) earlier in the treatment algorithm 1
• Monitor closely for treatment failure 1
• Consider fungal culture with susceptibility testing if refractory 1

Common Pitfalls to Avoid

• Do not assume angular cheilitis is purely nutritional—it most commonly has mixed infectious etiology 5
• In patients with macrocytic anemia, always measure both folate and B12 simultaneously to avoid masking B12 deficiency with folate supplementation alone 5
• Avoid chronic petroleum-based products on lips 1
• Distinguish from actinic cheilitis, a premalignant condition requiring different treatment approaches 1