What is the appropriate management of angular cheilitis in an adult with risk factors such as denture wear, xerostomia, nutritional deficiencies, or chronic lip licking?

Management of Angular Cheilitis

Start with a topical combination of hydrocortisone 1% plus an antifungal (miconazole 2% or clotrimazole 1%) applied 2-3 times daily for 1-2 weeks, as this addresses both the inflammatory and infectious components that drive angular cheilitis. 1

First-Line Pharmacologic Treatment

The cornerstone of therapy is combination topical treatment that simultaneously targets Candida infection and reduces inflammation:

• Apply hydrocortisone 1% with miconazole 2% (Daktacort) or clotrimazole 1% (Canesten HC) 2-3 times daily for 1-2 weeks 1
• Use cream formulation if the lesion is weeping or moist; use ointment if the skin is dry 1
• The antifungal component addresses Candida colonization while the corticosteroid reduces inflammation and discomfort 1

Alternative Combination Product

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

Monotherapy Options When Combination Therapy Unavailable

If the infection appears primarily fungal:

• 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

If the infection appears primarily bacterial:

• Antiseptic oral rinse containing chlorhexidine 0.2% twice daily 1

Systemic Therapy for Resistant Cases

• Fluconazole 100 mg orally once daily for 7-14 days is indicated for cases resistant to topical agents or when rapid fungal eradication is needed 1
• Consider systemic fluconazole earlier in immunocompromised patients 1
• If no improvement after 2 weeks of topical therapy, reevaluate the diagnosis and patient compliance 1

Essential Supportive Measures

Lip Protection Protocol

• Apply white soft paraffin ointment to the lips every 2-4 hours throughout treatment 1
• Avoid chronic use of petroleum-based products (e.g., Vaseline) as they promote mucosal dehydration and create an occlusive environment that favors secondary infection 2, 1

Oral Hygiene Regimen

• Use alcohol-free mouthwash to avoid additional mucosal irritation 1
• Brush with a soft-bristled toothbrush and mild fluoride toothpaste twice daily 1
• Perform warm saline mouthwashes daily 1

Addressing Mechanical and Systemic Risk Factors

Denture-Related Factors (Critical for Prevention of Recurrence)

• Promptly evaluate and correct ill-fitting dentures by a dental professional, as this is essential to resolve the underlying mechanical irritation 1
• Remove dentures as often as possible during the acute phase until lesions heal 1
• Soak dentures for 10 minutes in 0.2% chlorhexidine solution before reinsertion to eliminate microbial reservoirs 1
• Thoroughly disinfect dentures after each use, as they act as a reservoir for recurrent infection 1

Systemic Evaluation

• Evaluate for diabetes, immunosuppression, and other systemic conditions that predispose to angular cheilitis 1
• Review medications that may contribute (e.g., those causing xerostomia) 1
• Address behavioral habits including lip licking and mouth breathing 1
• Consider nutritional deficiencies (iron, B vitamins, zinc) and supplement if indicated 3

Special Populations

Immunocompromised Patients

• More aggressive and prolonged antifungal therapy is required 1
• Consider systemic fluconazole (100 mg/day for 7-14 days) earlier in the treatment algorithm 1
• Monitor closely for treatment failure and consider fungal culture with susceptibility testing if refractory 1

Treatment Monitoring and Follow-Up

• If no improvement after 2 weeks, reevaluate for correct diagnosis and patient compliance 1
• Distinguish angular cheilitis from actinic cheilitis, a premalignant condition requiring different treatment 1
• Obtain cultures if bacterial or candidal infection is suspected to guide antimicrobial therapy 1

Critical Pitfalls to Avoid

• Do not use petroleum jelly chronically on the lips—it increases infection risk despite being commonly recommended 2, 1
• Do not overlook denture fit as a mechanical cause—failure to address this leads to treatment failure and recurrence 1
• Do not delay systemic antifungals in immunocompromised patients—topical therapy alone is often insufficient 1
• Do not use alcohol-containing mouthwashes—they worsen mucosal irritation and delay healing 1