April 25, 2021
Angular Cheilitis is a condition that affects the lips and the facial skin in its proximity. Angular refers to the corner of the lip. Cheilitis is a word derived from the Greek work "cheilos" meaning lips. The suffix -itis represents inflammation. Thus, inflammation at the corner of lips is called angular cheilitis.
Angular Cheilitis appears as an inflamed discontinuity in the corner of the lips. Red ulcerations with inconsistent borders can be seen from the corner of the lips and can extend to the peripheral skin. The cause of such ulcerations can be local or systemic. Local causes involve ill-fitting dentures, loss of vertical height of the face due to loss of teeth and smoking. These conditions or habits reduce the flow of saliva in the mouth which subsequently dries the region of the oral cavity near the lips. The lack of needed moisture dries up the skin, creating cracks in the corner of the lips and its borders and thereby allowing microorganisms to invade the region.
Local causes of angular cheilitis can also include patients with a habit of mouth breathing. The passage of air through the mouth while breathing yet again is the source for drying the corners of the lips. Malnutrition and loss in weight is yet another cause of angular cheilitis. Deficiency of iron and certain vitamins are the reasons for the development of ulcerations. This is commonly seen in children in developing countries. Children and adolescents who are undergoing orthodontic treatment (braces) or have got their tonsils removed, are at a risk of developing angular cheilitis.
More specific local causes of angular cheilitis can be traced by microbiological tests. Microbial families of fungi and other pathogenic species like Candida, Streptococci and Staphylococci are the prime reasons for causing crustations and rhagades.
Systemic causes of angular cheilits involve a range of factors. These include conditions that a patient is already suffering from and angular cheilitis simply manifests as a result of the same. These conditions are xerostomia (dry mouth), diabetes mellitus, HIV/AIDS, secondary syphilis, patients undergoing radiotherapy, development of tumours and neurological disorders. Furthermore, there are disorders of genetic origin that also have angular cheilitis as one of the signs. These include Down's Syndrome, Orofacial Granulomatosis, Crohn's disease and autoimmune bullous disease. Consumption of drugs like metronidazole, paroxetin, tetracyclines, secukinumab can change the tonicity of the skin and pave the way for the development of angular cheilitis.
Since there are multiple reasons that can lead to angular cheilitis, treatment of the same is largely dependent on the underlying diagnosis. Antifungal agents like nystatin and amphotericin B can be consumed for subsiding the lesion. Application of gel based antifungal agents (while wearing gloves) like miconazole for four times a day across two weeks has also proved to be effective. Creams based agents like pimecrolimus too helps in resolving angulsr cheilitis. Recently, in 2016, application of ozonized olive oil was able to heal angular cheilitis in ten patients in a time span of 2-3 days.
Patients who are malnourished or have weight loss or have deficiency of vitamins are given supplements for the same. A dietary schedule is often drawn for such patients after knowing the deficient element(s) through lab tests.
Surgical approach to angular cheilitis is rare but can be carried out in severe and discomforting cases. These surgeries usually involve excising the ulcerations under general anesthesia and later covering the removed tissues with flaps from adjacent skin. Injections that are collagen or hyaluronic acid based have shown promising results in adults and old-aged patients. Laser therapy, specifically photodynamic therapy has been effective in not only removal of the lesion but also quick healing of the surgical site.
The current first line of treatment should certainly be application of gels or creams as surgical approaches have their own limitations. Currently, a combination of 1% isoconazole nitrate and diflucortolone valerate is said to be extremely effective in countering angular cheilitis. Fast disappearance of itchiness, redness and ulcerations along with rapid healing of the lesions are seen following the application of this combination for two weeks, twice a day.
Angular Cheilitis is a condition seen across all ages even though less frequent. Following the diagnosis, antifungal agents should be the first line of treatment. If recurrence occurs, further investigations need to be carried out to know the underlying cause. Only in the most severe cases should the surgical approach be preferred.