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“Angular Chelitis.” also known as “perleche,” is a relatively common problem with a prevalence rate of 0.7-3.8% in adults and 0.2-15.1% in children. This condition is most commonly linked to fungal infections. However, there are other associated factors, such as iron and vitamin deficiencies, loss of vertical height of mouth, and use of dental dentures. Because of its frequent occurrence, understanding the disease, its etiological factors, signs, and symptoms becomes necessary.
1. What is Angular Cheilitis?
Angular Cheilitis, also called “angular stomatitis,” is a common medical condition characterized by inflammation of commissural areas of the lip. To put it in simpler terms- Angular Cheilitis is inflammation of the lips. Anatomically, it initiates from the mucocutaneous junction and extends to the skin.
An environment that is chronic and conducive to the growth of microorganisms is suitable for developing Angular Cheilitis.
Angular Stomatitis can occur unilaterally or bilaterally, i.e., it can affect a single side of your mouth or both. Redness, irritation, loosening, and crustation of the corners of the mouth identify Angular Cheilitis.
2. Who is most affected? The Epidemiology-
With an overall prevalence rate of 0.7% in American population, cases of Angular Cheilitis is most commonly seen in-
- Children and Adults(30-60 years) are frequently affected.
- 11 percent prevalence rate is observed in elderly people.
- Men are affected more severely than females.
- An impressive 28 percent incidence is seen in denture wearers.
- People with predisposing factors such as Diabetes, Crohn’s Disease, AIDS are more commonly affected by Angular Stomatitis.
3. The Causative Factors-
Angular Cheilitis is multifactorial and can be divided into- local factors and systemic factors. A single causative factor can manifest angular cheilitis in an individual, or combined factors could also precipitate it.
3.1 The Local Factors-
Let us assess the local etiological factors involved in developing Angular Cheilitis under the following groups- anatomical causes, allergic causes, and infectious causes.
- Loss of vertical dimension of the jaw- Edentulous individuals or the ones suffering from periodontitis (with tooth migration) with misaligned teeth usually encounter a reduction in the vertical height of their jaw.
- Traumatic injuries due to ill-fitting dentures and faulty orthodontic appliances.
- Habits such as thumb sucking, repeated lip biting, and mouth breathing can also precipitate Denture Stomatitis.
- Loosening of facial tissue, resulting in sagging of the corners of the mouth. This condition is common in people undergoing massive weight loss.
- Materials like Nickel, Cobalt, Palladium, and Mercury used in the manufacturing of dental appliances can result in Angular Cheilitis.
- Allergic reactions are due to fragrant and flavoring agents(cinnamon, clove, methanol, peppermint) in lipsticks, chewing gum, cigarettes, and oral hygiene products.
- Existing stomatitis aggravates due to contact dermatitis.
- Fungal infections from Candida Albicans
- Bacterial infection from Staphylococcus aureus and Streptococcus.
- From a combination of C.Albicans and S.Aureus.
- Combined effects of Beta hemolytic streptococci and Staphylococcus manifest Angular Cheilitis in 8-15 percent of patients.
All these factors result in the pooling of saliva at the corner angle of the mouth. The salivary enzymes like amylase, lipase, catalase, and sulfatase cause skin irritation and inflammation at the commissure region.
3.2 The Systemic Factors-
Systemic factors, including Nutritional deficiencies, Chronic disorders, and Pharmacological agents, are responsible for Angular Cheilitis.
- Iron Deficiency Anaemia- Patients with symptomatic and asymptomatic iron deficiency anemia demonstrate symptoms of Angular Cheilitis. Reduced serum transferrin levels predispose an individual to candida infection, thus creating a suitable habitat for developing stomatitis.
- Vitamin B complex Deficiency- Deficiency of water-soluble vitamins such as riboflavin(Vit B12), cyanocobalamin(Vit B12), niacin(Vit B3), pyridoxine(Vit B6).
- Deficiency of folic acid- Angular Cheilitis that manifests due to folic acid deficiency generally precipitates with burning mouth syndrome(severe burning in the entire oral cavity) and glossodynia (pain in the tongue).
- Xerostomia- Salivary gland disorders, Sjogren syndrome, Crohn’s Disease, and Head and Neck Radiation result in xerostomia linked to Angular Cheilitis. It is one of the most common causes of Angular Cheilitis.
- 5.6-28.99 percent of HIV patients develop Angular Cheilitis. Moreover, it is also the most common oral manifestation in HIV-positive children.
- Severely compromised immunity and susceptibility to Candida infections make patients with long-term Diabetes Mellitus prone to Angular Cheilitis.
- It is also a common manifestation in patients suffering from eating disorders as anorexia nervosa and bulimia.
- 18% of patients with Discoid Lupus Erythematosus(skin-related autoimmune disorder) develop Angular Cheilitis.
- Patients with Down’s Syndrome(a genetic disorder) exhibit signs and symptoms of Angular Cheilitis.
- Precipitation of Angular Cheilitis is a side effect of the following pharmacological agents- Metronidazole, Paroxetine, Secukinumab, Warfarin, Benzodiazepines, Dexamethasone, Cyclosporine, and Digoxin.
- Incidence of Angular Cheilitis is also seen in patients with a rare pancreatic endocrine tumour, gluconoma. The syndrome presents with signs of diabetes, anemia, weight loss and angular stomatitis.
4. Signs and Symptoms-
Signs and symptoms of Angular Cheilitis vary as the disease progresses. Therefore, patient history plays a crucial role in disease assessment and diagnosis. The presentation may also differ in cases associated with systemic disorders. To avoid confusion, let us structure the features of Angular Stomatitis under the following headings-
4.1 Patient’s Complaint/ Symptoms-
- Pain around the corners of the mouth. Pain could be mild to severe in intensity.
- A discomfort expressed as itchiness, dryness, burning, or soreness.
- Difficulty in chewing and swallowing.
- Pain and discomfort are pronounced on opening the mouth. Everyday conversations might become troublesome.
- Patients might have a history of diarrhea, stomachache, dry mouth, and eyes.
4.2 Clinical Presentation-
- Because Angular Cheilitis is an inflammatory condition, it presents with erythematous (reddish), pruritic (itchy), swollen, and painful patches.
- The stomatitis patches are typically triangular.
- As the condition progresses, the color of the patch changes from red to greyish-white with red margins to bluish-white.
- Mature lesions will have fissures and crustations.
- Angular Cheilitis, due to bacterial involvement, will exhibit honey-colored patches.
- Chronic cases develop suppuration(exudation of pus) and form granulation tissue.
- The cheilitis patches might be present, along with oral candidiasis(oral thrush)and leukoplakia.
4.3 Presentation when associated with systemic conditions-
- Angular Stomatitis may present along with glossitis(inflammation of the tongue), hair loss, and spoon-shaped nails in patients with Iron Deficiency Anemia.
- A deficiency of Vit B12 causes Megaloblastic Anaemia that is present in the form of loss of peripheral sensations(numbness or tingling in fingers and toes), glossitis, and Angular Cheilitis.
- Patients with Vitamin B6 deficiency show psychiatric symptoms along with aphthous ulcers and angular stomatitis.
- Those with Ulcerative Colitis, Inflammatory Bowel Disease, and Crohn’s Disease will display signs of fissures, aphthous ulcers, glossitis, and angular cheilitis.
5. Angular Cheilitis and Cold Sores-
Often, a misconception persists among people who confuse angular cheilitis for cold sores. Let us address it briefly.
What are Cold Sores?
It is an infectious disease caused by Herpes Simplex virus. Medically, these patches are denoted as Herpetic lesions.
Similarity between Angular Cheilitis and Cold Sores-
The presentation of long standing Herpetic lesions evolve from macules to encrustations which resemble crustations visible in Angular Cheilitis.
Distinguishing features between Angular Stomatitis and Herpes Simplex Lesions-
|Candida and Staphylococcus
6. Differential Diagnosis(Other Similar Looking Lesions)-
Besides Herpetic blisters, there are few more conditions which mimic features similar to Angular Cheilitis. These are-
- Secondary Syphilis (syphilitic papules)
- Atopic Dermatitis
- Allergic cheilitis
- Erosive Lichen Planus
- Lichenoid reactions
- Seborrheic Dermatitis
If you suspect symptoms of Angular Stomatitis, you should consult your dermatologist (skin specialist). They are the ones who would confirm and manage your condition.
- Evaluation of the clinical features. Diagnosis of Angular Cheilitis depends on clinical presentation.
- Laboratory investigation to confirm Candida involvement. This includes Light Microscopy, Fungal Culture, and Immunodiagnosis.
- Bacterial culture will evaluate the involvement of Staphylococcus.
- Other Laboratory Investigations- Serum vitamin levels, serum iron profile, HbA1C(glucose monitoring).
- Patch test to exclude allergic reactions.
The main aim of managing any ailment is to treat it at the root level. Therefore, the management of Angular Cheilitis will depend on the causative factor. However, providing relief and restoring routine activities.
Treatment of Angular Cheilitis will include-
8.1 General Measures/Symptomatic Treatment-
- Hydration is the prime key.
- Application of petroleum jelly. It keeps the painful patches moist, thus reducing discomfort while talking and chewing.
- Application of local antiseptic(Fusidic Acid 2%)
8.2 Pharmacological Management-
- Amphotericin B
If the stomatitis lesion presents an erythematosus boundary surrounding the fissures, a mild topical application of steroid will help subside the inflammation.
Out of these antifungal, topical(local) treatment with azoles such as Miconazole is the treatment of choice for Angular Cheilitis. It is because of its effect on both S.Aureus(bacteria) and Candida strain(fungus) infecting the lesion.
- Fusidic Acid
Both of these are applied topically in cases where Angular Cheilitis manifests due to bacterial involvement.
8.3 Dental Management-
- Reclining or refitting of ill-fit/loose dentures.
- Orthodontic management of misaligned teeth.
- Recontouring of sharp edges of teeth.
- Replacement of faulty restorations.
- Injectable fillers like Hyaluronic acid are also recommended by dental professionals to restore the elasticity of the drooping lips.
- Similar to Hyaluronic Acid, use of Botulinum toxin is also promoted to ease the wrinkles at the corner of mouth.
8.4 Management of systemic diseases-
- Management of raised blood glucose levels via lifestyle modifications and medicines. Regular monitoring is a must.
- Antiretroviral medications for HIV-positive patients.
- Nutritional supplements to restore Vit B complex levels and to manage iron deficiency anaemia.
8.5 Habit Management-
- Cessation of cigarette smoking(it leads to candida infection at comissures superadded with leukoplakia)
- Use of habit-breaking appliances to control lip biting, mouth breathing, and thumb sucking.
All these measures will reduce discomfort and heal the Angular Cheilitis lesions. So many management options can be mind-boggling. So, to save you from stress, here is a summarised version including the etiologies and management directed to resolve them-
|Loss of vertical dimensionIll-fitting dental appliances and RestorationsDrooling of saliva
Habits(lip biting, thumb sucking)
|Denture fabricationFabrication of fit appliancesAnti-drooling prosthesisHabit breaking appliances
|Allergy to dental materials
Use of fragrant and flavouring agents
|Alternative to allergy causing material. Use of Nickel free components.Avoid using products with allergens.
|Topical or systemic AntifungalsTopical Antibacterial ointmentAntiretroviral drugs.
9. Preventive Measures-
As the age old aphorism goes- Prevention is better than cure. Yes, like for any major disease, it’s true for Angular Cheilitis too. Here are some useful tips that you can follow-
- Practise a healthy lifestyle. Have a healthy diet. Consume food items rich in vitamins and minerals. Keep yourself hydrated. Take adequate sleep and follow a workout regimen.
- Regular Health Checkups. It will give you an idea about serum deficiencies. Any systemic issue can be diagnosed and addressed at the right time.
- Routine glucose monitoring. Diabetes is a household disease and individuals above 40 years of age are highly susceptible to it. Thus, routine laboratory investigations will assist in managing the condition wisely.
- Stay away from known allergens and irritants.
- Try to break the lip, sucking and biting. If you find it difficult, consult your dentist.
- Say NO to cigarettes and tobacco-containing products.
- Seek treatment for crooked teeth.
- Consult a dental health professional in case of any impinging tooth or restoration.
- Visit the dentist for denture fabrication or readjustment of loose-fitting dentures.
- Keep your lips moisturised. This goes a long way as both prevention and management. Keep drinking fluids and apply petroleum jelly or any preferred moisturiser.
- Look for expired cosmetic products.
- Maintain good oral health.
- Denture hygiene must be followed diligently by denture wearers which will prevent development of candida infection.
10. Quick Home Remedies-
Angular Cheilitis is a common incident. Having some handy home tips can always be fruitful. So, here are few household products that will help you smile with ease even with cracked mouth angles-
- Aloe Vera Gel- It is a well-known anti-inflammatory which is commonly used to soothe irritated skin. Application of aloe vera gel over the cheilitis patches for around 10-15 minutes will calm the burning and itching.
- Cucumber- Take a thin slice of cucumber and leave it at the top of the lesion. In no time, the cooling action of cucumber will give you relief.
- Honey- The anti-bacterial and anti-inflammatory properties of honey is beneficial in Angular Cheilitis.
- Coconut Oil- Coconut oil can nullify the microbial damage caused by Candida strain. It also soothes the irritated skin.
- Baking Soda- Use Baking Soda to bake your cake and also avail its antibacterial properties to heal angular cheilitis.
Angular cheekbones are self-healing lesions, which means that even if not treated, the clinical symptoms will subside within a week or two.
Although long-standing cases require management, the overall outcome is positive. Angular Cheilitis is not a serious disorder. However, if left untreated for a long duration, the lesion can result in scarring or pigmentation of the affected skin.
Some individuals with chronic systemic diseases observe a recurrence of Angular Cheilitis Lesions. Prevention and self-management work best in such cases.
12. The Closing Notes-
Angular Cheilitis has a bimodal age distribution with frequent prevalence among children and adults between 30-60 years of age. Men are commonly affected. Other risk factors include dental prosthetic use, presence of systemic disorders, HIV positive, iron and Vitamin B complex deficiency.
Drooling saliva, Candida infection, and Bacterial involvement result in the formation of erythematosus, pruritic patches of Angular Cheilitis that turn into crustaceans in long-standing cases. The clinical presentation of Angular Cheilitis might be confused with cold sore blisters. However, the latter results from Herpes Simplex infection and is contagious.
Management is both symptomatic and definitive. It includes pharmacological approach involving use of Antifungals, Antibacterial ointments. Dental manipulation of loosely fit dentures and faulty restorations and replacement of allergic restorations are also part of the mainstay treatment. Application of injectable fillers and Botox are also a common therapeutic practice with positive outcomes.
Increased water intake, regular use of petroleum jelly, and leading a healthy lifestyle are some preventive measures against the lesion. Home remedies like aloe vera, homey, and baking soda can also help heal. Angular cheekbones are self-healing lesions. However, recurrent and chronic cases must seek physician consultation. A little self-awareness and guidance from doctors aid in quick healing.