Angular cheilitis
It’s not just thumb-sucking kids who have it
by John Kraft, MD and Charles Lynde, MD
Vol.17, No.03, March 2009

 A 46-year-old gentlemen presents with a 2-month history of burning and redness at the commissures of the lips. He admits to licking his lips. He’s a borderline diabetic controlled with diet and exercise alone. He isn’t on any medications.

Angular cheilitis, also known as perleche, is a chronic inflammatory condition of the angles of the mouth. It’s often multifactorial with many triggers and aggravating factors. Mechanical reasons for excessive wetness or dryness of the lips are very common. Habits such as frequent lip licking, or thumb sucking in children promote angular cheilitis. Other mechanical causes include flossing teeth, denture use, sagging skin leading to overhanging cheeks or lips, and too little or too much saliva. Alternating wetting and drying of the lips disrupts the barrier function and promotes cracking and fissures.

Infectious agents such as yeast and bacteria grow very well in moist environments such as wet angles of the mouth. Candida albicans and Staphylococcus aureus are common colonizers that promote angular cheilitis.

Angular cheilitis can also be associated with nutritional and systemic diseases. These include iron deficiency anemia, riboflavin, folate and B12 deficiencies. Systemic diseases associated with this skin condition include diabetes mellitus, Crohn’s disease, Sjögren’s syndrome, HIV and Down’s syndrome. Dermatological conditions such as eczema, perioral dermatitis and orofacial granulomatosis can also be predisposing.

Clinical findings

The commissures (corners) of the lips show erythema, scaling, maceration, atrophy, crusting and fissures. The fissures radiate down and away from commissures. Patients usually complain of soreness.

Lesions can be unilateral or bilateral. Unilateral lesions resolve quicker than bilateral ones, and tend to be due to trauma. Bilateral lesions are more chronic and are more likely associated with an underlying disease.

Differential diagnosis

Consider the following conditions in anyone who presents with scaly lips. Actinic cheilitis is a reaction to excessive sun exposure analogous to actinic keratoses of the skin. It often involves only the lower lip with scale, fissures and erosions. Allergic contact dermatitis (ACD) is much more prominent over the vermillion border and angular cheilitis is usually also present. Common triggering allergens of lip ACD include lip balms, lipsticks, topical medicines and toothpastes — especially cinnamon-flavoured varieties.

Cheilitis can also be secondary to seborrheic dermatitis, atopic dermatitis, psoriasis and retinoids.

Investigations

Consider the following investigations in patients presenting with angular cheilitis:

  • CBC, ferritin, B12, folate, fasting blood sugar, HbA1C
  • swab for bacterial culture and sensitivity, and candidiasis

Consider referral to dermatologist who may biopsy any lesions suspicious of malignancy, e.g. if there is induration or ulceration. The dermatologist may also see about patch testing if it’s a possible ACD.

Treatment

The keys to successful management include treating any underlying causes and modifying habits that may worsen the condition. Patients should be instructed to ensure optimal denture fit, and remove dentures nightly with regular cleansing.

Tell patients to apply a barrier moisturizer to the lips frequently. Have them try petroleum jelly or zinc oxide ointments, especially before bed and meals. Topical antifungals that are effective against yeasts are the mainstay of therapy. Clotrimazole and nystatin creams are good options. Use topical antibiotics if bacterial superinfection is likely. Fusidic acid, polymyxin B, and mupirocin are possible options. Mild topical corticosteroids and topical calcineurin inhibitors (pimecrolimus, tacrolimus) are additional options if inflammation is obvious. Combinations such as 1% hydrocortisone in clotrimazole cream can also be helpful.

If these aren’t effective, oral antifungals, e.g. fluconazole, should be considered. Mechanical correction of deep folds, such as collagen injection, is rarely done for select cases.

Case discussion

We discussed the nature of angular cheilitis with our patient, and took swabs for bacterial and fungal culture and sensitivity. Blood work included CBC, ferritin, fasting blood sugar and HbA1C. We instructed our patient to avoid lip licking and cinnamon-flavoured toothpaste, and to apply petroleum jelly to the lips and angles before eating and sleep. We also prescribed clotrimazole cream to use twice daily at the angles of the mouth.

Charles Lynde, MD, FRCP(C) is an assistant professor of dermatology at the University of Toronto.

John Kraft, MD, is in his third year of the Dermatology Residency Program at the University of Toronto.

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