Girl With Soreness at Corners of the Mouth

What's Your Diagnosis?
Sharpen Your Physical Diagnostic Skills

HISTORY

A 6-year-old girl presented with a 2-week history of soreness and a burning sensation at the corners of her mouth. Her past health was unremarkable, and she was taking no medications.

PHYSICAL EXAMINATION

Physical examination revealed a healthy girl with moist maceration and crust formation at the corners of the mouth.

What’s Your Diagnosis?

(Answer and discussion on next page)

ANSWER: Angular cheilitis

Cheilitis refers to inflammation of the lip surface characterized by dry scaling and fissuring.¹ Angular cheilitis refers to cheilitis radiating from the corners of the mouth. Synonyms for angular cheilitis include perlèche (derived from the French pourlécher, “to lick [one’s lips]”), commissural cheilitis, and angular stomatitis.²

INCIDENCE

The exact incidence is not known. It is estimated that angular cheilitis accounts for 0.2% to 15.1% of all oral mucosal lesions in children and 0.7% to 3.8% of all oral mucosal lesions in adults.^3-5 The sex ratio is approximately equal.

ETIOLOGY

Angular cheilitis is a multifactorial condition of which the causative factors may act alone or in combination. Local causes such as irritant contact dermatitis, allergic contact dermatitis, and infections are the most common factors. The skin at the corner of the mouth is subject to maceration due to collection of saliva in that area. As such, children with excessive salivation and drooling are more prone to the development of angular cheilitis, as are children who are mouth breathers when they sleep. Saliva contains food irritants as well as enzymes such as amylase, maltase, catalase, and lipase that may result in irritant contact dermatitis. Irritant contact dermatitis may predispose the child to superimposed allergic contact dermatitis due to increased penetration of allergens at the affected site.¹ Secondary infection with Candida albicans, staphylococci, streptococci, and saprophytic facultative microorganisms may occur.⁶ Friction or mechanical trauma such as lip licking, thumb sucking, and biting of or picking at the corners of the mouth also may contribute.⁶ In older patients, angular cheilitis may result from age-related sagging at the commissures of the mouth (eg, from mandibular osteoporosis), ill-fitting dentures, or orthodontic treatment.⁷

Occasionally, angular cheilitis may be a manifestation of a systemic disease, secondary to nutritional deficiency, or an adverse effect of certain medications. Systemic diseases associated with angular cheilitis include inflammatory bowel disease (Crohn disease, ulcerative colitis), diabetes mellitus, systemic lupus erythematosus, Down syndrome, Sjögren syndrome, and Plummer-Vinson syndrome.^8,9 Angular cheilitis may herald a variety of nutritional deficiencies such as iron, zinc, riboflavin (vitamin B₂), pyridoxine (vitamin B₆), cyanocobalamin (vitamin B₁₂), folic acid, and niacin deficiency.^9,10 Angular cheilitis may occur as an adverse effect of certain medications such as isotretinoin and paroxetine.^10,11

CLINICAL MANIFESTATIONS

Angular cheilitis is characterized by erythema, maceration, ulceration, scaling fissures, and crusting at the corners of the mouth.¹ The lesion usually starts as a grayish white thickening with adjacent erythema at the corners of the mouth. The lesion evolves over time with worsening erythema, maceration, ulceration, and crust formation. Angular cheilitis usually is bilateral but can be unilateral. There may be associated pain, burning sensation, or pruritus; patients particularly complain of discomfort when opening their mouth wide.

DIAGNOSIS

The diagnosis usually is made on clinical grounds. Diagnostic workup usually is not necessary. Bacterial cultures and potassium hydroxide wet-mount examination of skin scrapings of the lesion may be considered in selected cases.

DIFFERENTIAL DIAGNOSIS

The differential diagnoses include herpes labialis, herpetic gingivostomatitis, aphthous stomatitis, and herpangina. The distinctive features of each condition allow a straightforward differentiation from angular cheilitis.

MANAGEMENT

Treatment of angular cheilitis should be directed to the underlying cause if possible. General measures include proper oral hygiene and use of a barrier cream such as zinc oxide paste or petrolatum ointment. Angular cheilitis secondary to candidal infection should be treated with topical antifungals such as ketoconazole or ciclopirox olamine cream, nystatin suspension or troches, clotrimazole troches, or fluconazole suspension.^2,12 Although seldom required, systemic antifungals such as fluconazole, ketoconazole, and itraconazole should be considered for patients who have C albicans infection refractory to topical antifungal therapy.¹² Patients with angular cheilitis secondary to bacterial infection may be treated with a topical antibiotic such as mupirocin or fusidic acid. A mild cortisone such as 1% hydrocortisone cream or powder can be added to topical antibiotics or antifungals to expedite healing. In situations where the microbial culprit is unclear, a combination cream containing an antibiotic, an antifungal, and/or a mild corticosteroid can be considered.n

REFERENCES:

1. Park KK, Brodell RT, Helms SE. Angular cheilitis, part 2: nutritional, systemic, and drug-related causes and treatment. Cutis. 2011;88(1):27-32.

2. Skinner N, Junker JA, Flake D, Hoffman R. Clinical inquires: what is angular cheilitis and how it is treated? J Fam Pract. 2005;54(5):470-471.

3. Ogunbiyi AO, Owoaje E, Ndahi A. Prevalence of skin disorders in school children in Ibadan, Nigeria. Pediatr Dermatol. 2005;22(1):6-10.

4. Parlak AH, Koybasi S, Yavuz T, et al. Prevalence of oral lesions in 13- to 16-year-old students in Duzce, Turkey. Oral Dis. 2006;12(6):553-558.

5. Shulman JD. Prevalence of oral mucosal lesions in children and youths in the USA. Int J Paediatr Dent. 2005;15(2):89-97.

6. Sharon V, Fazel N. Oral candidiasis and angular cheilitis. Dermatol Ther. 2010;23(3):230-242.

7. Cross D, Eide ML, Kotinas A. The clinical features of angular cheilitis occurring during orthodontic treatment: a multi-centre observational study. J Orthod. 2010;37(2):80-86.

8. Bangsgaard N, Weile B, Skov L. Organised angular cheilitis as the initial sign of Crohn’s disease in two children. Acta Derm Venereol. 2011;91(2):207-208.

9. Park KK, Brodell RT, Helms SE. Angular cheilitis, part 1: local etiologies. Cutis. 2011;87(6):289-295.

10. Centers for Disease Control and Prevention. Malnutrition and micronutrient deficiencies among Bhutanese refugee children—Nepal, 2007. MMWR Morb Mortal Wkly Rep. 2008;57(14):370-373.

11. Verma R, Balhara YP, Deshpande SN. Angular cheilitis after paroxetine treatment. J Clin Psychopharmacol. 2012;32(1):150-151.

12. Gonsalves WC, Chi AC, Neville BW. Common oral lesions: part I: superficial mucosal lesions. Am Fam Physician. 2007;75(4):501-507.