Angular Cheilitis: What it is, Symptoms, Causes & Treatments

“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, other associated factors include 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 simply, 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 the American population, cases of Angular Cheilitis are most commonly seen in

• Children and Adults(30-60 years) are frequently affected.

• An eleven per cent prevalence rate is observed in elderly people.

• Men are affected more severely than females. 

• An impressive 28 per cent incidence is seen in denture wearers. 

• People with predisposing factors such as Diabetes, Crohn’s Disease, and AIDS are more commonly affected by Angular Stomatitis.

3. The Causative Factors-

Angular Cheilitis is multifactorial and can be divided into local 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. 

Anatomical Causes- 

• Loss of vertical dimension of the jaw—Edentulous individuals or those 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.

Allergic Causes-

• 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.

Microbial Causes-

• 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 saliva pooling at the mouth’s corner angle. 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).

• Folic acid deficiency —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. 

• The incidence of Angular Cheilitis is also seen in patients with a rare pancreatic endocrine tumour, glaucoma. 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 when 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-coloured patches.

• Chronic cases develop suppuration(exudation of pus) and form granulation tissue.

• The cheilitis patches, along with oral candidiasis(oral thrush)and leukoplakia, might be present.

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 vitamin B12 deficiency causes megaloblastic anemia, which manifests as 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 evolves from macules to encrustations, which resemble crustations visible in Angular Cheilitis.

Distinguishing features between Angular Stomatitis and Herpes Simplex Lesions-

Features	Angular Cheilitis	Cold Sores
Causative Agents	Candida and Staphylococcus	Herpes Simplex
Location	Usually Bilateral	Unilateral
Spread	Non-Contagious	Contagious
Fever	Not necessary	Present(Viral Lesion)

6. Differential Diagnosis(Other Similar Looking Lesions)-

Besides Herpetic blisters, a few more conditions mimic features similar to Angular Cheilitis. These are-

• Secondary Syphilis (syphilitic papules)

• Atopic Dermatitis

• Allergic cheilitis

• Erosive Lichen Planus

• Lichenoid reactions

• Seborrheic Dermatitis

7. Diagnosis-

If you suspect symptoms of Angular Stomatitis, you should consult your dermatologist (skin specialist). They will 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.

8. Management-

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-

Antifungal-

• Nystatin
• Amphotericin B
• Clotrimazole
• Miconazole
• Ketoconazole
• Fluconazole
• Itraconazole

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) treatments with azoles, such as Miconazole, are the treatments of choice for Angular Cheilitis. It is because of its effect on both S.Aureus(bacteria) and Candida strain(fungus) infecting the lesion.

Antibacterial-

• Fusidic Acid
• Mupirocin 

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 vitamin B complex levels and to manage iron deficiency anemia.

8.5 Habit Management-

• Cessation of cigarette smoking(it leads to candida infection at commissures 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-

Etiological group	Causes	Management
Anatomical causes	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
Allergic causes	Allergy to dental materials  Use of fragrant and flavouring agents	Allergy to dental materials  Use of fragrant and flavoring agents
Infectious Causes	Candida Staphylococcus Viral(HIV)	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-

• Practice a healthy lifestyle, eat a healthy diet, consume food rich in vitamins and minerals, keep yourself hydrated, get 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 over 40 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 if you need any impinging tooth or restoration.

• Visit the dentist for denture fabrication or readjustment of loose-fitting dentures.

• Keep your lips moisturized. This goes a long way as both prevention and management. Keep drinking fluids and apply petroleum jelly or any preferred moisturizer.

• 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 a few household products that will help you smile with ease even with cracked mouth angles-

• Aloe Vera Gel—Aloe vera gel is a well-known anti-inflammatory commonly used to soothe irritated skin. Applying aloe vera gel over the cheilitis patches for 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. The cucumber’s cooling action will quickly 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.

11. Prognosis-

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, faulty restorations, and replacement of allergic restorations are also part of the mainstay treatment. The application of injectable fillers and Botox is also a common therapeutic practice that has positive outcomes.

Increased water intake, regular petroleum jelly use, and a healthy lifestyle are preventive measures against the lesion. Home remedies like aloe vera, honey, 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. 

Last Updated on March 24, 2024 by Gautam