Angular Cheilitis – Stages, Causes, Risk Factors and Treatment

Definition

Angular cheilitis is a medical condition popularly known as “angular stomatitis that is characterized by cracked skin or wounds in the corner of the mouth where the lips meet. It is ​​​​caused by the overdevelopment of fungi or bacteria, and can happen from habits like constantly licking your lips. These sores can affect only one side of the mouth or both sides, and are associated with symptoms like pain, redness and peeling in the corners of the mouth, as well as difficulty in opening the mouth and even eating.

Since it caused by fungi or bacteria, angular cheilitis can be passed on to other people through kissing or using the same cup or cutlery, for example. Treatment typically includes the use of an antibiotic or antimycotic medication.

Pathophysiology

Pathophysiology is multifactorial and may involve interplay of physical conditions promoting a moist environment at the oral commissures and infectious agents. Although C albicans can exist harmoniously in the oral cavity, it is thought to contribute to the pathophysiology of angular cheilitis. A higher incidence of C albicans in affected individuals versus unaffected control patients and observed improvement of the condition with anti-candidal treatment supports this supposition. Other pathogens implicated in angular cheilitis include methicillin-sensitive S aureus, Streptococcus spp and gram negative bacteria.

Types of Angular Cheilitis

Stage 1: Minor Angular Cheilitis

Minor Angular Cheilitis is characterized by small flaky skin at the corners of the mouth. When you are in this stage, you will also experience tightness at the corners of the mouth and slight discomfort whenever you try to open the mouth wide.

Stage 2: Mild Angular Cheilitis

When you are suffering from mild Angular Cheilitis, you will start to notice discomfort and tightness in the corners of your mouth. You will also start seeing flaky skin and redness at the corners of the mouth. You feel uncomfortable whenever you try to open your mouth wide.

Stage 3: Severe Angular Cheilitis

This stage is characterized by pain and discomfort whenever you try to talk, eat or do anything else that requires you to open your mouth. It will be easy for you and others to notice the lesions in the corners of your mouth. Neosporin, chapstick and other ointments that are usually used to heal Angular Cheilitis will not work.

Stage 4: Chronic Angular Cheilitis

When you are suffering from Chronic Angular Cheilitis, you will heal over several month but the symptoms will come back again. Dryness and cracks as a result of Angular Cheilitis will always cause severe discomfort and pain.

Causes of Angular Cheilitis

Fungal and bacterial infections are the most common cause of angular cheilitis. Bacterial or Candida infections are common recurring causes.

Bacterial infections, including staphylococcal and beta-hemolytic streptococcal, are common causes of angular cheilitis in children.

Some health conditions can also lead to the development of angular cheilitis. Conditions include:

• Atopic dermatitis (an inflammatory skin condition)
• Conditions that cause macroglossia (a disorder in which the tongue is larger than normal), such as Down syndrome and congenital hypothyroidism
• Lupus erythematosus (an autoimmune condition causing inflammation that damages connective tissue)
• Erythema multiforme (a skin reaction triggered by an infection or certain medications)
• Crohn’s disease (an inflammatory bowel disease)
• Sarcoidosis (a systemic inflammatory disease that produces clumps of cells called granulomas)
• Diabetes (a condition in which blood sugar levels are high)
• Inflammatory bowel disease (ongoing inflammation causes diarrhea, abdominal pain, and other symptoms)
• Vitamin and mineral deficiencies

Additional causes of angular cheilitis:

• Dentures that don’t fit well
• Drooling during sleep
• Misaligned teeth or poor bite
• Wearing a face mask
• Skin allergies
• Sucking on a pacifier or thumb

If your doctor can’t find the cause of your angular cheilitis, it is called idiopathic angular cheilitis.

Symptoms of Angular Cheilitis

The symptoms of angular cheilitis are probably obvious to anyone who’s had them. In general they can include:

• A whitening or thickening of the skin around the corners of your mouth
• Redness and swelling in the area
• Cracking or crusting at the corners of your mouth
• Pain or soreness
• Burning

You might only experience these symptoms on one side of your mouth, or they might appear on both sides. Although these symptoms are usually only noticeable in the area around your mouth, in extreme cases they can extend all the way to your cheek.

Risk factors

Diabetes can weaken the immune system, making it more vulnerable to the yeast infections associated with AC. Many people with diabetes develop skin problems, including infections. Diabetes can also damage a person’s gums and teeth, leading to tooth loss and dentures and further increasing the risk of AC.

Other risk factors include:

Sensitivity and allergies: People who have allergic dermatitis or a history of atopic dermatitis tend to be more sensitive to:

• dental care products, such as toothpaste and mouthwash
• nickel in orthodontic braces
• certain ingredients in lip cosmetics
• certain ingredients in acne products
• specific foods, due to flavorings and preservatives

A weak immune system: For example, HIV and AIDS and chemotherapy treatment can affect a person’s immune system.

Genetics: Having a genetic condition, such as Down syndrome.

Nutritional issues: These include anemia or a poor diet, both of which can make the body more vulnerable to certain infections.

Thrush: A yeast infection of the mouth.

Tooth and gum issues: Wearing dentures, particularly if they are badly fitting or having a poor bite.

A virus or infection in or near the mouth: For example, a cold sore.

Very dry and chapped lips: If the lips are so dry they crack open, it is easier for viruses, bacteria, and yeast to invade.

Vitamin and mineral deficiencies: These include people with vitamin B, zinc, and iron deficiencies, which can affect older people and those who have had bariatric surgery. It can also affect individuals who have the following conditions:

• Celiac disease
• Chronic gastritis
• Chronic pancreatitis
• Inflammatory bowel disease
• Sjogren’s disease

Complications

Chronic, untreated angular cheilitis can cause scarring or discoloration of the skin at the corners of the lips. The condition can also cause tissue atrophy, where the tissues start to shrink, which can change a person’s appearance. However, doctors don’t usually associate angular cheilitis with severe medical side effects.

Diagnosis

Your primary healthcare provider or a dermatologist (provider specializing in skin conditions) can diagnose angular cheilitis. They will:

• Check your symptoms.
• Perform a physical exam.
• Review your medical history.

They may do a mouth swab to test for viruses like herpes or fungal infections. Blood tests check for illnesses or nutritional deficiencies.

Treatment

As with all medical conditions, consult your Doctor for the diagnosis and treatment of angular cheilitis. The cause of this condition will determine the treatment. Most cases of angular cheilitis are infectious and will be treated as such. Your GP may advise one of the following treatments:

• Anti-fungal and/or anti-bacterial medications
• Decreased saliva production may be managed by drugs that stimulate saliva production or artificial saliva
• Allergies or reactions to oral cleansers, toothpastes and other topical agents are best managed by switching to a different, non-reactive product.

Your Doctor will advise you on the best way to manage a side effect of, or allergy to, certain prescription and non-prescription medications. If ill-fitting dentures are causing the condition, your GP will refer you to a dentist. In some cases, iron-replacement therapy for patients suffering from iron-deficiency anemia is an effective treatment for angular cheilitis. As a general rule, all patients should maintain good oral hygiene to prevent recurrence.

Diet hints

Supplements may be of assistance if dietary intake is inadequate. Dietary deficiency of certain vitamins and minerals can cause angular cheilitis. These include:

Riboflavine (Vitamin B2): Major food sources include milk and dairy products, cereals, brewer’s yeast, meats (especially organ meats), and some green leafy vegetables.

Niacin (Vitamin B3): Major food sources include peanuts, rice, bean, liver, kidney, food yeasts, avocado, fish, eggs and lean meats.

Pyridoxine (Vitamin B6): Major food sources include yeast, brown rice, sunflower seed, rice, soya beans, nuts, egg yolk, bananas, rockmelon, liver, wheat germ, fish, chicken, beef, potatoes, cauliflower, cabbage and avocados. Foods that have been processed such as breads, cakes and confectionery contain almost no vitamin B6.

Iron: See the Iron Deficiency Diet on Healthpoint.

Prevention of Angular Cheilitis

• Good hygiene and strict skin care can help prevent angular cheilitis. By keeping the skin moistened around your mouth and free from irritation, you can help reduce the likelihood of bacteria or yeast buildup.
• You may want to consider applying petroleum jelly or coconut oil to the corners of your mouth, which can form a barrier from saliva. Also, using lip balm regularly can help prevent chapped, dry lips.
• You’ll also want to take steps to prevent dry mouth, which can trigger increased saliva production.
• If it is caused by the structure of the creases in your mouth, talk to your doctor about oral appliances or fillers that can help.