Angular cheilitis (PerlIche)


Angular cheilitis also called perlIche, cheilosis or angular stomatitis.

Cheilosis is an inflammatory lesion at the corner of the mouth.

Part candida infection and part inflammatory reaction to impaired epidermal integrity.

Cheilosis often occurs bilaterally.

Clinically manifests as deep cracks or splits, that may bleed.

May be associated with shallow ulcers or a crusting.

May be caused by nutritional deficiencies, fungal infections, or bacterial infections.

May become infected by the fungus Candida albicans or other pathogens.

Initial onset of angular cheilitis may be related to nutritional deficiencies, namely riboflavin and iron deficiency anemia, which in turn may be evidence of poor diets or malnutrition.

May be associated with zinc deficiency, anorexia nervosa/bulimia nervosa, and Plummer-Vinson syndrome.

Occurs frequently in the elderly population with loss of teeth, manifesting as over-closure of the mouth.

Associated with chapped lips.

It can also be caused by medications which dry the skin, such as isotretinoin.

Associated with hypervitaminosis A.

Treatment of angular cheilitis varies depending on the cause.

For lesions caused by bacterial infection, applying a topical antibiotic is appropriate.

Cases caused by a fungal infection can be treated by antifungal creams.

Angular cheilitis, also called rhagades, perlIf he, cheilosis, angular cheilosis, commissural cheilitis, or angular stomatitis.

Refers to inflammation of one, or more commonly both, of the corners of the mouth.

It is a type of inflammation of the lips and is the second most common type of lip infection.

Often represents an opportunistic infection of fungi and/or bacteria.

A relatively common condition, accounting for between 0.7-3.8% of oral mucosal lesions in adults and between 0.2-15.1% in children.

Occurs most commonly in adults in the third to sixth decades of life.

The most common presentation of fungal and bacterial infections of the lips.

There are multiple local and systemic predisposing factors involved oin the initiation and persistence of the lesion.

Such varying factors include: nutritional deficiencies, overclosure of the jaw/mouth, dry mouth, lip-licking, drooling, immunosuppression, and poor fitted dentures.

Treatment based on the causes.

A common problem, and is more prevalent in denture wearers, and the elderly, although it may also occur in children.

Considered to be a type of stomatitis.

When Candida species are involved, it is classified as a type of oral candidiasis.

Classified as acute or chronic and refractory.

Its appearance is variable.

More commonly present on both sides of the mouth.

May be confined to the mucosa of the lips, or in may extend past the vermilion border onto the facial skin.

The corners of the mouth initially develop a gray-white thickening and adjacent erythema.

The appearance is a roughly triangular area of erythema, edema and breakdown of skin at either corner of the mouth.

The lips may become cracked, crusted, ulcerated or atrophied.

Not usually associated with bleeding.

There may be radiating linear fissures from the corner of the mouth.

The dermatitis can extend from the corner of the mouth to the skin of the cheek or chin.

In chronic disease , there may be pus formation, exfoliation and granulation tissue.

Contributing factors can be related to loss of lower face height from poorly made or worn dentures, which results in mandibular overclosure.

If a nutritional deficiency underlies the condition, other signs and symptoms such as glossitis may be present.

In individuals with angular cheilitis who wear dentures, often there may be erythematous mucosa underneath the denture with soreness, pain, itching or burning.

A disorder of infectious origin,with many predisposing factors.

The lesions are often infected with fungi, or sometimes bacteria, or a combination and may represent a secondary, opportunistic infection.

Some studies link the onset of angular cheilitis with nutritional deficiencies, especially of the B vitamins and iron.

Angular cheilitis may be evidence of malnutrition or malabsorption.

Can be a manifestation of contact dermatitis,

Candida species, usually Candida albicans, accounts for about 20% of cases,

Staphylococcus aureus accounts for about 20% of cases,

?-hemolytic streptococci bacteria have been detected in between 8-15% of cases of angular cheilitis,

About 60% of cases involving both C. albicans and S. aureus.

Candida can be detected in 93% of cases, and is found in the mouths of about 40% of healthy individuals.

Candida is considered by some to be normal commensal component of the oral microbiota.

Candida shows dimorphism, firstly a yeast form which is thought to be relatively harmless and a pathogenic hyphal form which is associated with invasion of host tissues.

Potassium hydroxide preparation can distinguish between the harmless and the pathogenic forms.

22% of cases of angular cheilitis are due to irritants.

Saliva contains digestive enzymes, which have a degree digestive action on tissues if they are left in contact., and

the corner of the mouth is normally exposed to saliva more than any other part of the lips.

Reduced lower facial height (vertical is usually caused by edentulism, or wearing worn down, old dentures or ones which are not designed optimally, resulting in overclosure of the mandible.

Overclosure of the mandible extenuates the angular skin folds at the corners of the mouth, creating an intertriginous skin crease with tendency of saliva to pool in these areas.

The constant wetting of the area, may cause tissue maceration and favors the development of a yeast infections.

More commonly seen in edentulous people and by contrast uncommon in persons who retain their natural teeth.

Commonly seen in denture wearers.

Angular cheilitis is present in about 30% of people with denture-related stomatitis.

Reduced vertical dimension of the lower face may be a contributing factor in up to 11% of elderly persons with angular cheilitis and in up to 18% of denture wearers who have angular cheilitis.

Situations that keep the corners of the mouth moist include: chronic lip licking, thumb sucking, or sucking on other objects such as pens, pipes, lollipops, flossing, chewing gum, hypersalivation, drooling and mouth breathing.

Less severe cases may occur during cold, dry weather, and is a form of chapped lips.

Licking of the lips Individuals may worsen the condition.

Expired lipbalm can initiate angular cheilitis.

Several different nutritional deficiency states of vitamins or minerals have been linked.

In about 25% of people with angular cheilitis iron deficiency or deficiency of B vitamins are involved.

Any cause of immunocompromise may allow an opportunistic infection of candida.

Vitamin B2 deficiency may also cause AC, and commonly occurs together with folate deficiency.

Vitamin B3 deficiency (pellagra) is associated with dermatitis, diarrhea, dementia and glossitis

Biotin (vitamin B7) deficiency has also been associated along with alopecia and dry eyes.

Zinc deficiency is known to cause AC, along with include diarrhea, alopecia and dermatitis.

Acrodermatitis enteropathica is an autosomal recessive genetic disorder causing impaired absorption of zinc, and is associated with AC.

Nutritional disorders may be caused by malnutrition, such as may occur in alcoholism or in strict vegan diets, or by malabsorption secondary to gastrointestinal disorders or gastrointestinal surgeries.

Some systemic disorders associated with malabsorption and the creation of nutritional deficiencies include people with anorexia nervosa.

Xerostomia accounts for about 5% of cases of AC.

Xerostomia is commonly the caused by side effects of medications, or conditions such as Sjogren’s syndrome.

Conditions which cause drooling or sialorrhoea can cause angular cheilitis by creating a constant wet environment in the corners of the mouth.

About 25% of people with Down syndrome appear to have AC, due to relative macroglossia, which may constantly stick out of the mouth causing maceration of the corners of the mouth with saliva.

Inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis can be associated with angular cheilitis.

It occurs in Crohn’s disease likely as the result of malabsorption and immunosuppressive therapy.

Glucagonomas are rare pancreatic endocrine tumors which secrete glucagon, and cause dermatitis, glucose intolerance, weight loss and anemia and AC.

May be a manifestation of chronic mucocutaneous candidiasis.

Sometimes oropharyngeal or esophageal candidiasis may accompany angular cheilitis.

Angular cheilitis may be present in HIV infection, neutropenia, or diabetes.

More common in people with eczema because their skin is more sensitive to irritants.

Several drugs may cause AC such as creating drug-induced xerostomia and include isotretinoin, indinavir, and sorafenib.

Associated with hypervitaminosis A, which can occur when large amounts of liver, or from an excess intake of vitamin A in the form of vitamin supplements.

Recreational drug users may develop AC, and include cocaine, methamphetamines, heroin, and hallucinogens.

Allergic reactions may account for about 25-34% of cases of generalized cheilitis, that is inflammation not confined to the angles of the mouth.

Allergens include some types of lipstick, toothpaste, acne products, cosmetics, chewing gum, mouthwash, foods, dental appliances, and materials from dentures or mercury containing amalgam fillings.

Diagnosis usually made clinically.

If the lesion is unilateral, rather than bilateral, a local factor is suggested.

Bilateral disease may be related to mandibular overclosure, drooling, and other irritants.

The lesions are normally swabbed to detect if Candida or pathogenic bacterial species may be present,

and in those who wear dentures, their dentures should be swabbed.

In the treatment of angular cheilitis:

Potential reservoirs of infection inside the mouth are identified and treated.

Oral candidiasis, especially denture-related stomatitis is often found to be present where there is angular cheilitis, and if it is not treated, the sores at the corners of the mouth may often recur.

Dentures should be properly fitted and disinfected.

Attempt to increase the vertical dimension of the lower face to prevent overclosure of the mouth and formation of deep skin folds that may require the construction of a new denture with an adjusted bite, collagen injections to restore the normal facial contour.

Other measures including improving oral hygiene, stopping smoking or other tobacco habits and use of a barrier cream at night.

Treatment of the infection and inflammation of the lesions themselves is addressed is usually with topical antifungal medication, such as clotrimazole, amphotericin, ketoconazole, or nystatin cream.

Some antifungal creams are combined with corticosteroids to reduce inflammation, and some antifungals such as miconazole cream also have some antibacterial action.

Diiodohydroxyquinoline, fusidic acid cream, neomycin, mupirocin, metronidazole, and chlorhexidine, are options for treatment when Staphylococci is involved in angular cheilitis.

Identification of the underlying cause is essential for treating chronic cases.

In most cases of angular cheilitis respond quickly when antifungal treatment is used.

In long standing cases, the condition often follows a relapsing and remitting course over time.

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