Angular cheilitis

perleche · angular stomatitis · commissural stomatitis · rhagades · angular cheilosis

Sore, fissured corners of the mouth - usually candidal, staphylococcal or both, and occasionally the visible end of a nutritional or systemic problem.

GPBand C

Red flags

A child or adult with recurrent or refractory candidal infection - consider undiagnosed diabetes, immunosuppression or HIV, and test rather than simply re-treating
Weight loss, fatigue, glossitis or pallor alongside it - iron, folate or B12 deficiency is a recognised association and needs bloods rather than another cream
A persistent, indurated or non-healing lesion at the commissure that does not behave like cheilitis - this needs a lesion-focused referral, not repeated antifungals
Angular cheilitis in a child with faltering growth or a restricted diet - a nutritional and safeguarding assessment, not a dermatological one

Recognise

On light skin

Red, macerated, fissured skin at one or both angles of the mouth, sometimes with crusting, and sore or stinging on opening the mouth or eating.

On brown and black skin

The erythema that makes this obvious in pale skin is frequently not visible, and the corners of the mouth may instead look darker, violaceous or simply hyperpigmented against surrounding skin - so the condition is easy to under-call as dry lips. The tone-independent findings are structural and symptomatic: maceration and a softened, soggy surface, a visible fissure or split running out from the commissure, crusting, and pain on opening the mouth, smiling or eating acidic food. Ask rather than only look. Post-inflammatory hyperpigmentation at the angles is common afterwards and can take a long time to fade, and patients often present for that rather than for the original soreness - it is not active infection and it is not scarring.

In any skin tone

Both corners of the mouth, more often than one - a strictly unilateral lesion should make you think again
Maceration, fissuring and crusting at the commissure, sore on mouth opening
Look inside the mouth: coexisting oral candidiasis points to the commonest cause
Ask about anything that keeps the corners wet - drooling, lip-licking, a new orthodontic appliance
In older adults, ask about dentures and the fit of them; in children, about thumb-sucking, dummies and lip-licking

Distribution

The angles of the mouth (labial commissures), usually both sides, at the junction between facial skin and oral mucosa.

Photographs

Bilateral angular cheilitis in an older person with dentures. Both corners of the mouth are red, macerated and fissured, with the inflammation spreading a short way onto the surrounding skin. **That it is bilateral and confined to the commissures is the whole diagnosis** - a single painful crusted lesion at one corner is more likely herpes simplex. Deep folds from worn dentition keep the corners wet, which is what lets Candida and staphylococci in; look also for iron, folate or B12 deficiency, and for denture-related oral candidiasis inside the mouth. This patient gave written consent for clinical photography and for reuse under this licence. The only openly licensed photograph found for this entry shows light skin. **That is a limitation of this page, not of the disease** - a darker-skin photograph is still being sought.
Fitzpatrick II (Fitzpatrick type estimated from the photograph, not stated by the source) · Matthew Ferguson 57 · Wikimedia Commons - Angular cheilitis1.jpg · CC BY-SA 3.0

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Cutaneous candidiasis — Candidal infection is the commonest cause rather than a separate diagnosis - look in the mouth for coexisting oral candidiasis
Herpes simplex — A cold sore can sit at the commissure, but it begins with tingling, is grouped and vesicular, and is usually unilateral
Atopic eczema and infected eczema — Lip-licker's dermatitis gives a ring of dryness and scaling around the whole mouth rather than disease confined to the angles
Syphilis - the secondary rash — Split papules at the oral commissures are a recognised, easily missed feature of secondary syphilis - consider it where there is a wider rash, palm and sole involvement or a sexual history

What to do in the ED

Look in the mouth, not just at the corners - oral candidiasis alongside it settles the likely cause and changes the treatment
There is no NICE CKS topic for angular cheilitis, and no UK national guideline for it - so treat per local policy and the BNF rather than on a borrowed guideline. Conventional practice is a topical antifungal, with a combined antifungal and antibacterial preparation where crusting suggests staphylococcal involvement. No source is cited for that choice here because none could be traced; name the agent from your own formulary
Address the mechanical cause or it will recur - denture fit and denture hygiene in older adults, drooling and lip-licking in children, and anything that keeps the angles wet
Check for and treat an underlying cause where the history suggests one: consider iron, folate, B12 and glucose rather than a third course of cream
Advise a barrier ointment such as white soft paraffin at night to stop the fissure re-opening
Refer to dentistry for denture-related disease - it will not resolve while the denture is the cause

Disposition

Treat and discharge with GP follow-up. Refer to dentistry for denture-related cases, and arrange investigation rather than repeat treatment where it is recurrent or refractory.

Safety-netting

The corners of the mouth usually settle over a couple of weeks of treatment. Use the ointment at night to stop the skin splitting again. Come back, or see your GP, if it keeps returning after treatment, if you also feel tired or unwell or notice a sore tongue, or if it does not heal at all - recurrent cracking at the mouth corners is sometimes the first sign of something that needs a blood test. Darker marks left at the corners afterwards will fade slowly and are not scars.

Sources

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