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Top Symptoms and Causes Of Angular Cheilitis

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Angular cheilitis, also called angular stomatitis, is an inflammatory condition that occurs at one or both corners of the lips. The affected area(s) turn red, dry, and can cause a lot of irritation and pain. The causes of angular cheilitis can be external, internal, or a combination of both.

At What Age Does Angular Cheilitis Strike?

Angular cheilitis can affect anyone with a weakened immune system as the common causes are bacterial, viral, and fungal infections. It also depends on the lifestyle and any repetitive unhealthy habits. However, some studies show that people are more prone to it at their 30s, 50s, and 60s.1

More frequently, children who tend to drool while eating or sleeping can be affected easily. Pregnant women are more susceptible since pregnancy induces a lot of changes in the body. And lowered immunity and possible nutrient deficiencies can make the elderly easy targets.

What Are The Symptoms Of Angular Cheilitis?

Depending on the severity of the condition, you will observe few or all of these symptoms.2

  • You will notice a rigidness at the corner of your lips and discomfort in opening your mouth.
  • The spot(s) turn red and sore.
  • The skin in and around the affected area gets cracked, crusty, and scaly.

These symptoms usually fade with healthy habits and by not constantly licking the spot. If left untreated, the condition can get worse.

  • The affected area becomes swollen and might turn into ulcers.
  • It will lead to pus formation and ooze.
  • The spots will start to bleed.
  • You will experience an itchy, painful, and burning sensation.

If left untreated, this might spread to the adjacent skin and progress to more severe infections like impetigo, a contagious skin infection that can cause red sores on the face.

External Causes Of Angular Cheilitis

1. Due To Irritants

The skin at the corner of your lips is more sensitive than the rest of the lips. So a constant moist state due to saliva or external products or a reduced production of salivary enzymes can lead to inflammation and further allergy. If left for a prolonged period, it causes a deeper than normal fold in the area, leading to angular cheilitis.3

Anatomical Causes

Anatomical Causes Due To Irritants_External Causes Of Angular Cheilitis

Facial changes, abnormal teeth or skeletal growth, dental appliances such as dentures, and weight loss can cause a loss of proper facial support and lead to this condition. These factors are common in debilitated, elderly, and malnourished individuals.

Mechanical Causes

 

Mechanical Causes Due To Irritants_External Causes Of Angular Cheilitis

Smoking, dental flossing, breathing through the mouth, excessive drooling, lip licking, and other similar redundant behaviors can cause severe irritation in this spot and lead to angular cheilitis.

Chemical Causes

Chemical Causes Due To Irritants_External Causes Of Angular Cheilitis

Burns, excess saliva, and dental cleaning products can be harsh on the skin and cause irritation.

2. Due To Allergies

Substances you are allergic to that come in contact with the lip area or oral mucosa can induce angular cheilitis. And if an irritant is already present, it helps the allergen to penetrate deeper into the area, aggravating the condition. Here are some common substances that cause allergies:4

Additives

Additives Due To Allergies _External Causes Of Angular Cheilitis

Flavorings, fragrances, and other additives in products such as lip balms, aftershave lotions, cosmetics, cigarettes, foods, or other similar products

Metals

Metals Allergies _External Causes Of Angular Cheilitis

Nickel, gold, mercury, palladium, cobalt, etc., that are used in dentures, fillings, braces, spectacle frames, musical instruments, and any other equipment you come in contact with

Sunscreen

Sunscreen Allergies _External Causes Of Angular Cheilitis

Any products with sunscreen that might lead to chronic lip irritation

Preservatives

Preservatives Allergies _External Causes Of Angular Cheilitis

Preservatives, antiseptics, and antioxidants such as formaldehyde, propolis, etc., that are mostly used in cosmetic products like nail color, lotions, and lipstick and also products like gum and musical instrument varnish

Medications

Medications Allergies _External Causes Of Angular Cheilitis

Corticosteroids, neomycin, triclosan, or other chemicals in products like creams, ointments, toothpaste, and mouthwash

3. Due To Infections

Bacterial, fungal, and viral infections can aggravate and most often lead to other infections like angular cheilitis. The organisms that are most commonly seen in relation to this condition are given here:5 6

Candida albicans Fungi

Candida albicans Fungi Infections _External Causes Of Angular Cheilitis

Candida infection often leads to associated angular cheilitis. Studies have noticed approximately a 10% chance of both infections occurring together, which might relapse and increase in severity. Angular cheilitis due to candida has also been seen in those using medication such as isotretinoin for acne, which causes dry lips.7

Staphylococcus aureus And β-hemolytic streptococci Bacteria

Staphylococcus aureus And β-hemolytic streptococci Bacteria Infections _External Causes Of Angular Cheilitis

Staphylococcus aureus is present in the nose and is usually harmless. Related infections are caused only if they come in contact with the mouth, which can cause angular cheilitis.8

Herpes Simplex Virus

Herpes Simplex Virus Infections _External Causes Of Angular Cheilitis

A herpes simplex infection at the corner of the mouth can resemble angular cheilitis. This happens usually after 2–3 days when the skin turns crusty. Such an infection is most often the angular herpes simplex. It is important to get the diagnosis right before treating.

Internal Causes Of Angular Cheilitis

1. Due To Malnutrition

Internal Causes Of Angular Cheilitis Due To Malnutrition

Angular cheilitis is one of the ways in which multiple nutrient deficiencies manifest. Correct diagnosis becomes very important here as the deficiency can weaken the whole body. Lack of intake of the following vitamins can lead to angular cheilitis:9

  • Iron
  • Riboflavin or vitamin B2
  • Pyridoxine or vitamin B3
  • Vitamin B12
  • Folic acid
  • Zinc
  • Niacin

2. Due To Systemic/Other Medical Conditions

Down Syndrome

Down Syndrome_Internal Causes Of Angular Cheilitis Due To Systemic_Other Medical Conditions

In a study, about a quarter of the 77 participants studied with Down syndrome experienced angular cheilitis. Possible reasons for this include a skeletal structure that results in excessive drooling, protruding tongue that leads to excess salivation, a necessity to breathe through the mouth, and Candida albicans infection.10 11

Eating Disorders

Eating Disorders_Internal Causes Of Angular Cheilitis Due To Systemic_Other Medical Conditions

Those suffering from eating disorders usually have excessive nutrient deficiencies and low metabolism, low immunity that leads to infections, habits such as forced vomiting, and unhealthy personal hygiene. All of these can cause angular cheilitis.12

Crohn’s Disease

Crohn's Disease_Internal Causes Of Angular Cheilitis Due To Systemic_Other Medical Conditions

Crohn’s disease can affect all or any part of the gastrointestinal tract. And this includes the lips. Clubbed with nutrient deficiencies, this can result in angular cheilitis.13

Diabetes

Diabetes_Internal Causes Of Angular Cheilitis Due To Systemic_Other Medical Conditions

A dryness of the oral mucosa and a burning sensation in the mouth have been commonly seen in type-2 diabetes patients. When diabetes is left unregulated, along with Candida infections, it can lead to angular cheilitis.14

Oral Thrush

Oral Thrush_Internal Causes Of Angular Cheilitis Due To Systemic_Other Medical Conditions

Oral thrush/oral candidiasis is a Candida infection that occurs in the mouth, and one of the ways it manifests is in the form of angular cheilitis.15

Anemia

Anemia_Internal Causes Of Angular Cheilitis Due To Systemic_Other Medical Conditions

Iron deficiency/anemia not only makes a person more susceptible to heart issues and infections but also causes angular cheilitis. It is more common than any other oral issues in anemic people.16

Cancer

Cancer_Internal Causes Of Angular Cheilitis Due To Systemic_Other Medical Conditions

Angular cheilitis has been seen in advanced stages of cancer with a probable cause of lowered immune system or dryness of the mouth. One study also identified Candida albicans and few other organisms as probable causes.17

HIV

HIV_Internal Causes Of Angular Cheilitis Due To Systemic_Other Medical Conditions

Candida infection is one of the earliest signs of HIV, and it can appear in the form of angular cheilitis. According to one study, about one-third to half of HIV-positive people experience oral infections.18

Common Treatments

Most of the times, applying petroleum jelly on the affected area works. But for severe cases, the treatment of angular cheilitis depends on the cause. Most irritants can either be avoided or readjusted. These include unhealthy habits, loose-fitting facial equipment such as dentures, or trauma.

This goes for allergies too: You can recognize the allergens in cosmetics or other products that come in contact with your skin through close observation or through proper diagnosis and avoid using such products. For infection-related angular cheilitis, doctors prescribe specific medications targeting the infection-causing bacterium, virus, or fungi. For systemic causes, the treatment should target the actual medical condition that is the root cause.

A Few Good Habits To Follow

Healthy habits can prevent most of these factors from affecting you. Here are a few steps you can take:

  • Avoid poor-fitting dentures or other oral fittings. Also, keep the dentures clean every day to avoid infections.
  • Eat nutrient-rich foods and avoid any kind of deficiencies.
  • Avoid injuries or cuts in and around the lips.
  • Avoid foods, medications, or cosmetics that might cause allergies.
  • Quit smoking.
  • Avoid involuntary habits such as constantly licking your lips.

Make sure you consult your doctor if you experience persistent irritation, pain, or cracking that doesn’t go away with your regular lip balm.

References   [ + ]

1, 3, 4, 6. Park, Kelly K., Robert T. Brodell, and Stephen E. Helms. “Angular cheilitis, part 1: local etiologies.” Cutis 87, no. 6 (2011): 289.
2, 5. Warnakulasuriya, K. A. A. S., L. P. Samaranayake, and J. S. M. Peiris. “Angular cheilitis in a group of Sri Lankan adults: a clinical and microbiologic study.” Journal of oral pathology & medicine 20, no. 4 (1991): 172-175.
7. Gagari, Eleni. “Cheilitis and Oral Disease.” In European Handbook of Dermatological Treatments, pp. 133-141. Springer Berlin Heidelberg, 2015.
8. Angular Cheilitis. National Health Service, UK.
9. Park, Kelly K., Robert T. Brodell, and Stephen E. Helms. “Angular cheilitis, part 2: nutritional, systemic, and drug-related causes and treatment.” Cutis 88, no. 1 (2011): 27-32.
10. Scully, C., W. Van Bruggen, P. Diz Dios, B. Casal, S. Porter, and M‐F. Davison. “Down syndrome: lip lesions (angular stomatitis and fissures) and Candida albicans.” British Journal of Dermatology 147, no. 1 (2002): 37-40.
11. Pat Ansell PhD, R. H. V. “Oral disease in children with Down syndrome: causes and prevention.” Community practitioner 83, no. 2 (2010): 18.
12. Bhargava, Stuti, Mukta Bhagwandas Motwani, and Vinod Patni. “Oral implications of eating disorders: a review.” Arch. Orofac. Sci 8, no. 1 (2013): 1-8.
13. Plauth, Mathias, Harro Jenss, and Jörg Meyle. “Oral manifestations of Crohn’s disease: an analysis of 79 cases.” Journal of clinical gastroenterology 13, no. 1 (1991): 29-37.
14. Dorocka-Bobkowska, Barbara, Dorota Zozulinska-Ziolkiewicz, Bogna Wierusz-Wysocka, Wieslaw Hedzelek, Anna Szumala-Kakol, and Ejvind Budtz-Jörgensen. “Candida-associated denture stomatitis in type 2 diabetes mellitus.” Diabetes research and clinical practice 90, no. 1 (2010): 81-86.
15. Akpan, A., and R. Morgan. “Oral candidiasis.” Postgraduate medical journal 78, no. 922 (2002): 455-459.
16. Parlak, A. H., S. Koybasi, T. Yavuz, N. Yesildal, H. Anul, I. Aydogan, R. Cetinkaya, and A. Kavak. “Prevalence of oral lesions in 13‐to 16‐year‐old students in Duzce, Turkey.” Oral diseases 12, no. 6 (2006): 553-558.
17. Davies, Andrew N., Susan R. Brailsford, and David Beighton. “Oral candidosis in patients with advanced cancer.” Oral oncology 42, no. 7 (2006): 698-702.
18. Samaranayake, Lakshman P. “Oral mycoses in HIV infection.” Oral surgery, oral medicine, oral pathology 73, no. 2 (1992): 171-180.