What Is Angular Cheilitis?

Overview

Angular cheilitis is a kind of acute or chronic inflammation particularly affecting the corners of the mouth or oral commissures. The term angular cheilitis itself refers to inflammation at the angle of the mouth. It is clinically presented in the form of fissures (small tears), scaling, erythema (redness of the skin) and crusting.¹ Angular cheilitis is also called by various other terms such as angular stomatitis, cheilitis, rhagades and perleche. The angle of the mouth or the oral commissure is the place where the oral squamous epithelium and the oral mucosa meet. Thus they are more prone to stress, motion, and tensile strength than the rest of the lips. Angular cheilitis can occur at one side of the mouth or both. 

Angular cheilitis lasts for a week or more depending on the underlying cause. It has various underlying causes from infectious to non-infectious entities such as nutritional deficiency, mechanical irritation, or dermatological diseases. There is no age barrier to developing angular cheilitis. People with poor immunity or health are more susceptible to this kind of skin inflammation.

Causes of angular cheilitis

Angular stomatitis occurs at the oral commissure which is the meeting point of oral mucosa and facial skin. Thus they are vulnerable to stress or trauma while eating, drinking, and talking. Moreover, the prolonged exposure of the mouth corners towards saliva consisting of various digestive enzymes and the contact of both the lip corners can cause irritation followed by inflammation resulting in eczematous cheilitis. 

Initially, the lip corners appear grey or white and then they show redness or erythema. They then turn into triangular areas of erythema, swelling, and skin breakdown.²

 The various causes include:

• Allergic contact dermatitis: Caused due to some allergens, such as nickel in tooth braces, food flavourings or preservatives, mouthwash, toothpaste, and cosmetics.
• Immune deficiency: When a person is immune deficient he or she often develops oral thrush which extends towards the lip corner. Some of the immunosuppressive diseases include HIV, severe combined immunodeficiency syndrome (SCID), malignancies, and patients on long-term steroid use.
• Nutritional deficiency: This is a less common cause of angular cheilitis. However, mentally ill patients, coeliac disease patients, inflammatory bowel disease, Crohn’s disease, elderly citizens, vegans and breastfed infants without vitamin supplementation, patients who have undergone bariatric surgery, and ileal resection are susceptible. The major vitamin and mineral deficiency that results in angular cheilitis are vitamin B (vitamin B12, vitamin B2, vitamin B9), iron and zinc.³
• Systemic diseases: Angular cheilitis is caused as a result of some systemic diseases. One of the main symptoms of Sjogren's syndrome is dry mouth and reduced salivation. Salivary IgA helps in the flushing out of candida and therefore lack of salivation can provide a medium for fungal infection.
• Infection: Around 50-80% of swabs collected from the lesions show infective pathogens. Specifically candida albicans in the majority of cases, staphylococcus aureus and less commonly streptococcus species. These are the normal commensals of the mouth. As a result of poor oral hygiene, diabetes, immunodeficiencies and others trigger them into pathogenic forms. A smaller proportion of angular stomatitis is caused due to a viral infection, particularly herpes simplex virus. They are called angular herpes simplex, herpes labialis, or cold sore.
• Mechanical action or habit: Frequent licking of the lips, thumb sucking, drooling, and smoking.

Signs and symptoms of angular cheilitis

The following symptoms of angular stomatitis at the mouth corners are observed:

• Chapped lips
• Fissures (small tear and cut on the skin)
• Blisters 
• Skin erosions
• Oozing skin
• Crusting 
• Redness 
• Cracked corners
• Itching and pain
• Painful cracks

Angular stomatitis normally appears on either side of the lips (bilateral) and exhibits symmetry, however, if it occurs on one side, it should raise suspicion of malignancy if no known underlying causes are identified. Angular stomatitis can progress into impetigo and oral candidiasis. Licking the lips can make the scar worse.

There are 4 stages of angular cheilitis:

• Stage 1 (minor angular cheilitis); appears as flaky corners and tightness of the mouth, creating discomfort when you open the mouth. 
• Stage 2 (mild angular cheilitis); appears as reddened corners with an increase in discomfort.
• Stage 3 (severe angular cheilitis); simple activities such as the slight opening of the mouth becomes difficult and at this stage even treatment gets ineffective.
• Stage 4 (chronic angular cheilitis); the skin around the corner becomes dry and deep cracks appear. You might see the disappearance and reappearance of the symptom.⁴

Management and treatment for angular cheilitis

Treatment is based on the underlying infectious or non-infectious cause. Most cases of angular stomatitis do not require any kind of treatment as it resolves by itself.

Typically, within two weeks of time after a few days of treatment resolves the issue. Rarely, angular stomatitis results in pigmentation and scarring. Recurrence is normal in patients with non-modifiable risk factors.

Some of the treatment measures include:

• Dribbling of saliva at night is one of the reasons through which the lip corners get affected through saliva-induced eczema and maceration. To prevent excess saliva dribbling at night, emollient ointment, petroleum jelly and lip balm are used to protect the labial commissures. 
• Topical antifungal cream acts on fungal infection, such as candida, and also possess bacteriostatic action.
• Topical application of antiseptics and antibiotics are used for bacterial infection.
• The inflamed skin can be treated by using a topical steroid combination.
• Dentures should be removed at night and placed in a candidacidal solution. Poorly fitted dentures need to be replaced.
• Nutritional supplementation to overcome vitamin, mineral, and protein deficiencies.

Diagnosis

Diagnosis is mainly by understanding the patient’s history and knowing the underlying cause. Since most cases of angular stomatitis are due to infection, skin swabs from the affected area may help in revealing yeast infection, such as oral candidiasis or bacterial infection by Staphylococcus aureus. If there is no clinical improvement after 2-3 weeks of antifungal and antibiotic treatment, diagnostic tests are carried out. These include a complete blood count, folate and vitamin B2, B6 and B12, iron profile and ferritin, zinc, and glucose level. Occasionally, the cracked corners may involve herpes simplex virus and are confirmed through viral swabs. Skin biopsy is usually not recommended, only in case of suspected malignancy.

Risk factors

There are various risk factors that can predispose a person to angular stomatitis. These include:

• Dry chapped lips for any reason such as the use of medication like anticholinergic drugs and retinoids.
• Oral thrush as a result of microbes such as candida albicans or Staphylococcus aureus. 
• Dentures (artificial teeth) if they are not fitted appropriately and are associated with gum problems. Children wearing braces are more prone to angular cheilitis.
• Exaggerated skin folds especially in older individuals.⁵
• Any nutritional deficiency such as iron, vitamin B2 (riboflavin), vitamin B12, protein, zinc, and folate.
• Immunodeficiency patients, diabetics, patients on corticosteroid or antibiotic treatment.
• Systemic diseases, such as coeliac disease, inflammatory bowel disease such as Crohn’s disease and ulcerative colitis, Sjogren syndrome.
• Skin eczema 
• Down’s syndrome
• Licking the lips and drooling
• Allergies, sun exposure, smoking
• Rapid weight loss 
• Smoking

FAQs

How can I prevent angular cheilitis?

Maintain good oral hygiene, abstain from the risk factors and immediately consult a doctor for pathogenic infection of the mouth.

How common is angular cheilitis?

Angular cheilitis is the most commonly identified symptom observed in bacterial and fungal infections of the lips. 

When should I see a doctor?

When you experience symptoms such as pain, itchy, sore, irritated and burning sensations at the corners of your mouth, consult a doctor.

Summary

Angular cheilitis is an inflammatory skin condition whereby the corners of the mouth or labial commissures are affected. There are various risk factors associated with angular cheilitis from microbial infections, nutritional deficiencies, and systemic diseases. Diagnosis involves identifying the causative agent through microbial detection and looking out for nutritional deficiencies and figuring out the underlying cause. The general measures taken to treat angular stomatitis involve the application of topical antifungal cream, lip balm for dry lips, antifungal medication, steroid ointment for skin inflammation, nutritional supplements and recorrecting dentures.