Angular Cheilitis: Symptoms, Types, Causes and Treatment

Angular cheilitis is a deceptively simple but often frustrating condition that can affect anyone, causing discomfort and affecting quality of life. Found at the corners of the mouth, it’s a problem that is frequently encountered in both dental and medical clinics. This article provides an evidence-based, accessible, and comprehensive overview of angular cheilitis, including its symptoms, types, causes, and treatment options. Whether you are a patient, clinician, or simply curious, this guide will help you understand the nuances of this common but multifactorial disorder.

Symptoms of Angular Cheilitis

Angular cheilitis, also known as perlèche or commissural cheilitis, is marked by distinct features that make it both recognizable and uncomfortable. The symptoms range from mild irritation to more severe lesions, and their intensity can vary depending on the underlying cause and patient factors.

Symptom	Description	Severity Range	Sources
Erythema	Redness at mouth corners	Mild to severe	1 11 16
Maceration	Moist, softened skin	Mild to severe	1 2 11
Fissuring	Cracks or splits	Mild to severe	11 13 16
Ulceration	Surface breakdown	Moderate-severe	1 11 13
Crusting	Scab formation	Mild to severe	1 11 13
Pain/Burning	Discomfort or soreness	Mild to severe	2 11 13 16

Table 1: Key Symptoms

Common Clinical Features

The hallmark symptoms of angular cheilitis are:

• Redness (erythema): The skin at one or both corners of the mouth appears red and inflamed.
• Maceration: Prolonged moisture leads to softening and whitening of the skin, which can make the area prone to further breakdown.
• Fissuring and Ulceration: Small cracks, splits, or even shallow ulcers can develop, making movement of the mouth painful.
• Crusting: As the lesions heal or become chronic, yellowish or brownish crusts may develop at the site.
• Pain and Burning: Patients often complain of soreness, stinging, or a burning sensation, especially when eating, talking, or opening the mouth wide 1 2 11 13 16.

Severity and Duration

The severity of symptoms can range from mild redness to deep, painful fissures that bleed or crust over. In some cases, the lesions may be unilateral (one side) or bilateral (both sides), and may persist for days, weeks, or even longer if the underlying cause is not addressed 2 7 8. Associated symptoms can include:

• Swelling
• Itching
• Difficulty eating or speaking due to pain
• Secondary infection, leading to increased discomfort

Impact on Quality of Life

Despite being a relatively small area, angular cheilitis can significantly impact daily activities such as eating, smiling, and oral hygiene. Pain and visible lesions may also cause embarrassment and social discomfort 11 13.

Types of Angular Cheilitis

Angular cheilitis is not a one-size-fits-all condition. The clinical presentation, underlying causes, and even the microorganisms involved can vary. Understanding the different types helps clinicians tailor treatment and uncover potential systemic issues.

Type	Lesion Characteristics	Common in	Sources
Type I	Erythema only	Mild cases	6 7 8
Type II	Erythema + erosion/fissuring	Moderate cases	6 7 8
Type III	Erythema + crust/ulcer	Severe cases	6 8
Type IV	Mixed/atypical presentation	Complex/systemic	8

Table 2: Clinical Types of Angular Cheilitis

Type I: Erythematous Lesions

• Description: Presents as simple redness at the mouth corners, with no visible fissuring or crusts.
• Population: More common in mild or early cases, or in certain populations with less severe disease 7 8.

Type II: Eroded or Fissured Lesions

• Description: Shows both redness and visible cracks, erosions, or splits.
• Population: Frequently seen in moderate cases, and is often more symptomatic due to pain from fissuring 6 7 8.

Type III: Crusted or Ulcerated Lesions

• Description: Involves deeper tissue breakdown, with ulceration and sometimes yellowish or brownish crusts.
• Population: More common in severe or chronic cases, and among denture wearers or those with underlying systemic conditions 6 8.

Type IV: Mixed or Atypical Lesions

• Description: Presents with overlapping features, or in patterns that do not fit neatly into other types. May include mixed infections or be associated with other conditions (e.g., leukoplakia).
• Population: Seen in complex cases, or where multiple factors are involved 8.

Other Classifications

Some studies further classify angular cheilitis based on:

• Microbial flora: Pure fungal, pure bacterial, or mixed infections 7 8.
• Unilateral vs. Bilateral: Whether one or both mouth corners are involved 2 7.
• Acute vs. Chronic: Duration and recurrence of lesions 6 8 11.

Causes of Angular Cheilitis

The causes of angular cheilitis are multifactorial, involving local, systemic, infectious, and environmental factors. Proper identification of the cause is crucial for effective treatment and prevention of recurrence.

Cause Type	Description/Example	Key Factors	Sources
Infectious	Candida, Staph. aureus, Streptococci	Fungal, bacterial, mixed	1 5 6 7 8 11
Local	Moisture, lip licking, sagging skin	Chronic saliva exposure	1 11 12
Systemic	Nutritional deficiencies, diseases	Iron/B vitamins, Crohn’s	9 11
Mechanical	Denture use, loss of vertical height	Poor-fitting dentures	11 6 12
Allergic	Contact dermatitis, reactions	Cosmetics, oral care	1 10
Drug-related	Immunosuppressants, others	Side effects	9 15

Table 3: Key Causes of Angular Cheilitis

Infectious Causes

• Fungal: Candida species (especially C. albicans) are frequently isolated from lesions 5 6 7 8 11.
• Bacterial: Staphylococcus aureus is commonly found, sometimes mixed with Candida or Streptococcus species 5 7 8.
• Mixed Infections: Many patients have both fungal and bacterial involvement, which can complicate treatment 8.

Local Factors

• Excess Moisture: Chronic saliva pooling at the mouth corners (from drooling, lip licking, thumb sucking) creates a moist environment ideal for microbial growth 1 2 11.
• Anatomical Changes: Reduced vertical facial height (especially in denture wearers and older adults) leads to skin folds and maceration 11 12.
• Dental Factors: Ill-fitting dentures, loss of teeth, or dental attrition can alter oral anatomy and promote angular cheilitis 11 6 12.

Systemic and Nutritional Factors

• Nutritional Deficiencies: Lack of iron, riboflavin (B2), pyridoxine (B6), cobalamin (B12), and niacin are established risk factors 9 11.
• Systemic Diseases: Angular cheilitis can be a sign of underlying conditions such as diabetes, Crohn’s disease, ulcerative colitis, or Plummer-Vinson syndrome 9 11.
• Immunosuppression: Patients with reduced immunity (e.g., HIV/AIDS, cancer, immunosuppressive therapy) are more susceptible 11 15.

Allergic and Irritant Causes

• Contact Dermatitis: Allergic or irritant reactions to cosmetics, lip balms, toothpaste, or dental materials can cause localized inflammation at the mouth corners 1 10.
• Environmental Factors: Cold weather, wind, and frequent mask-wearing (notably observed during the COVID-19 pandemic) can precipitate or worsen angular cheilitis 2 10.

Drug-Induced Causes

• Some medications, especially those that suppress the immune system, can predispose to angular cheilitis or lead to recurrent episodes 9 15.

Treatment of Angular Cheilitis

Treatment of angular cheilitis is most effective when tailored to the underlying cause. While many cases can be managed with topical therapy, persistent or recurrent cases require a broader diagnostic and therapeutic approach.

Treatment	Mechanism/Use	Notes/Effectiveness	Sources
Topical Antifungals	Nystatin, Isoconazole, Amphotericin B	For Candida/infective cases	12 13 16
Topical Antibiotics	Fusidic acid, mupirocin	For bacterial involvement	12 13
Combination Therapy	Antifungal + anti-inflammatory	For mixed/complex cases	13
Address Cause	Denture adjustment, nutrition	Key for recurrence prevention	11 12 13
Oral Hygiene	Chlorhexidine mouthwash, xylitol	Adjunctive, especially elderly	2 16
Nutritional Supplementation	Iron, B vitamins	For deficiency-related cases	9 11 13

Table 4: Main Treatment Options for Angular Cheilitis

Topical Therapies

• Antifungal Creams: Nystatin, isoconazole nitrate, and amphotericin B are effective, especially when Candida is identified 12 13 16. Topical application directly to the lesion is standard.
• Antibacterial Ointments: Fusidic acid and mupirocin are used when bacterial pathogens, particularly Staph. aureus, are present. Combination therapy may be needed for mixed infections 12 13.

Adjunctive and Supportive Measures

• Improve Oral Hygiene: Regular use of chlorhexidine mouthwash or xylitol-containing gum can help reduce microbial load and support healing 2 16.
• Denture Management: Adjusting or replacing poorly fitting dentures, restoring vertical facial height, and proper denture hygiene are vital, especially in older adults 11 12.
• Moisture Control: Addressing habits like lip licking, and using barrier creams to reduce moisture can prevent recurrence 11 12.

Systemic and Nutritional Interventions

• Nutritional Supplementation: Correcting underlying deficiencies (iron, B vitamins) is essential in patients with documented nutritional issues 9 11 13.
• Treat Underlying Systemic Disease: If a systemic illness is identified, managing the primary disease is crucial to resolving angular cheilitis 9 11.

Other and Emerging Treatments

• Anti-inflammatory Agents: Topical corticosteroids (e.g., diflucortolone valerate) can help reduce inflammation but should be used with caution and typically in combination with antimicrobial agents 13.
• Photodynamic Therapy & Devices: Experimental treatments such as photodynamic therapy or anti-drooling prosthetic devices have been reported in case series but are not routine 13.

Treatment Duration and Monitoring

• Most cases respond to treatment within 2–6 weeks. Persistent or recurrent lesions warrant further investigation for underlying systemic or anatomical factors 12 13.
• Regular follow-up ensures healing and helps identify relapses early.

Conclusion

Angular cheilitis is a multifactorial and often recurrent condition that affects people of all ages. While it may seem minor, it can be a sign of broader systemic or nutritional issues and significantly impact quality of life. Here are the key takeaways:

• Angular cheilitis presents with redness, maceration, fissuring, and pain at the mouth corners, varying in severity and duration 1 2 11 13 16.
• There are several clinical types, from mild erythematous lesions to severe ulcerated or crusted forms, which can be unilateral or bilateral 6 7 8.
• Causes are multifactorial, including infectious (Candida, Staph. aureus), local (moisture, denture issues), systemic (nutritional deficiencies, diseases), allergic, and drug-induced factors 1 5 6 7 8 9 10 11 12 13 15.
• Treatment involves targeted topical antimicrobials, management of underlying causes (nutritional, dental, systemic), and supportive oral hygiene. Most cases resolve with appropriate therapy, but addressing the root cause is vital for lasting relief 11 12 13 16.

If you or someone you know suffers from persistent cracks or soreness at the corners of the mouth, consult a healthcare professional—not only for relief but to rule out more serious underlying conditions.