How should cheilosis (angular cheilitis) be managed?

Management of Cheilosis (Angular Cheilitis)

Begin treatment with a combination topical antifungal-corticosteroid preparation, specifically 1% isoconazole nitrate with 0.1% diflucortolone valerate ointment applied to affected corners of the mouth 2-3 times daily, while simultaneously investigating and correcting underlying nutritional deficiencies and local mechanical factors. 1

Immediate Therapeutic Intervention

First-Line Topical Treatment

• Apply combination 1% isoconazole nitrate and 0.1% diflucortolone valerate ointment as the most consistent treatment option, providing broad-spectrum coverage against dermatophytes, Candida species, and bacteria while reducing inflammation 1
• Alternative topical antifungals include nystatin oral suspension or miconazole oral gel if fungal infection is suspected as the primary etiology 2
• Consider topical antibacterial coverage with 0.2% chlorhexidine if secondary bacterial infection is present 3

Basic Oral Care Protocol

• Rinse mouth with warm saline or alcohol-free sodium bicarbonate-containing mouthwash 4-6 times daily to reduce bacterial colonization 3
• Use soft toothbrush after meals to maintain oral hygiene without additional trauma 3
• Avoid petroleum-based lip products as they promote mucosal dehydration and increase infection risk; instead use animal or plant-based oils such as beeswax, cocoa butter, or lanolin 4

Identify and Correct Underlying Etiologies

Nutritional Deficiency Assessment

Angular cheilitis is a classic manifestation of riboflavin (vitamin B2) deficiency, presenting with oral-buccal lesions including cheilosis, glossitis, and angular stomatitis 2

• Check riboflavin status in all patients with angular cheilitis, particularly those at risk: malabsorption syndromes (short bowel, celiac disease), thyroid dysfunction, diabetes, renal disease, alcoholism, elderly patients, and those on psychotropic drugs or barbiturates 2
• Measure erythrocyte glutathione reductase activity as the most reliable functional assay, especially in inflammatory conditions where plasma levels may be falsely low 2
• Treat confirmed riboflavin deficiency with oral supplementation of 50-100 mg daily for 1-2 weeks, noting that plasma levels plateau in 6-10 days 2
• Consider pyridoxine (vitamin B6) deficiency, which causes seborrheic dermatitis with cheilosis and angular stomatitis; treat with 50-100 mg orally for 1-2 weeks 2
• Evaluate for iron deficiency anemia and vitamin B12 deficiency, as these commonly present with angular cheilitis 5, 6

Mechanical and Local Factors

• Eliminate sources of mechanical trauma immediately: have dental team correct ill-fitting dentures, fractured teeth, or sharp dental restorations 4, 7
• Assess for decreased vertical dimension of occlusion causing skin folds at mouth corners where moisture and microorganisms accumulate 7, 8
• Evaluate for excessive drooling or saliva pooling, particularly in elderly or neurologically impaired patients 8

Infectious Considerations

• Angular cheilitis has mixed bacterial and fungal etiology in most cases 8
• Candida albicans is the most common fungal pathogen, found in oral cavity of up to two-thirds of healthy individuals 2
• Consider Staphylococcus aureus and beta-hemolytic streptococci as bacterial co-pathogens 7
• In HIV-infected patients or immunocompromised individuals, angular cheilitis may indicate progressive immunodeficiency and requires more aggressive antifungal therapy 2

Treatment Algorithm

Step 1: Apply combination topical antifungal-corticosteroid (isoconazole/diflucortolone) 2-3 times daily 1

Step 2: Implement basic oral hygiene with saline rinses 4-6 times daily and soft toothbrush 3

Step 3: Obtain laboratory testing including complete blood count, riboflavin status (erythrocyte glutathione reductase), vitamin B6, B12, iron studies, and fasting glucose 2, 4

Step 4: Correct identified nutritional deficiencies with appropriate supplementation (riboflavin 50-100 mg daily, pyridoxine 50-100 mg daily as indicated) 2

Step 5: Eliminate mechanical factors through dental intervention for ill-fitting prostheses or fractured teeth 4, 7

Step 6: If no improvement after 1-2 weeks, reassess diagnosis and consider biopsy to rule out other conditions (lupus, lichen planus, pemphigus) 4, 5

Critical Pitfalls to Avoid

• Do not use petroleum-based lip products, as they create an occlusive environment promoting mucosal dehydration and increasing secondary infection risk 4
• Avoid alcohol-based mouthwashes that cause additional pain and impair healing 3, 4
• Do not rely solely on antifungal treatment without investigating underlying nutritional and mechanical factors, as this addresses only one component of a multifactorial condition 5, 7, 6
• In patients with inflammation, use erythrocyte riboflavin measurements rather than plasma levels, as plasma concentrations decrease 30-40% with inflammatory response 2
• Consider that angular cheilitis may be the presenting sign of systemic disease including diabetes, immunodeficiency, or autoimmune conditions requiring further workup 5, 8, 6