Angular Cheilitis: Causes, Diagnosis, and Targeted Treatment

Angular cheilitis (perlèche) is inflammatory fissuring at the labial commissures. Multifactorial etiology requires targeted therapy.

Major Causes

Category	Examples
Nutritional	Iron, zinc, riboflavin (B2), niacin (B3), pyridoxine (B6), B12, folate deficiency
Infectious	Candida albicans (most common), Staph. aureus, Strep. spp.
Mechanical	Deep commissural folds (overclosure, denture loss), chronic lip licking, mouth breathing
Dermatologic	Atopic dermatitis, contact allergy (toothpaste, denture adhesive), psoriasis
Systemic	Diabetes, immunosuppression, HIV, inflammatory bowel disease
Drug-induced	Isotretinoin, diuretics, chemotherapy

Diagnostic Approach

• Swab for KOH prep, culture (Candida, bacteria).
• CBC, ferritin, B12, folate, zinc, glucose, HIV if indicated.
• Patch testing if contact allergy suspected.

Treatment by Etiology

• Candida: Topical antifungal (clotrimazole, nystatin, miconazole) ± mild topical steroid (hydrocortisone 1%) ×2 weeks.
• Staph: Topical mupirocin or fusidic acid.
• Nutritional: Replace deficient nutrient; B-complex + iron/zinc if multiple.
• Mechanical: Denture adjustment, vertical dimension restoration, barrier ointment (petrolatum).
• Idiopathic/refractory: Low-potency topical steroid + antifungal combo; TCIs (tacrolimus).

Prevention

Keep commissures dry, well-fitted dentures, address nutritional deficits, manage underlying disease.