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Often the corners of the lips are red with skin breakdown and crusting. The condition can last from days to years.
Cheilosis can be caused by infection, irritation, or allergies. Infections include fungi like Candida albicans and bacteria like Staph Aureus.
Irritants include ill-fitting dentures, lip licking or drooling, mouth breathing causing dry mouth, sun exposure, mouth wrapping, smoking, and minor trauma.
Allergies can include substances like toothpaste, makeup, and food. There are often a number of factors involved. Other factors can include poor nutrition or poor immune function.
Diagnosis can help with infection testing and allergy patch testing.
Treatment for cheilosis is usually based on the underlying causes along with the use of a protective cream. An antifungal and antibacterial cream is also often tried.
Cheilosis is a fairly common problem, with estimates that it affects 0.7% of the population.
It occurs most often between the ages of 30 and 60, although it is also relatively common in children. In the developing world, iron and vitamin deficiencies are a common cause.
Signs and symptoms of cheilosis
As there are different possible causes and contributing factors from one person to the next, the appearance of the injury is somewhat variable.
The usual appearance is a roughly triangular area of erythema, edema (swelling), and breakdown of the skin in any corner of the mouth.
The lining of the lip may fissure (crack), crust over, ulcerate, or atrophy. There is usually no bleeding.
Where the skin is involved, there may be radiant bursts (linear fissures) from the corner of the mouth. Infrequently, dermatitis (which can look like eczema) can spread from the corner of the mouth to the skin of the cheek or chin.
In chronic cheilosis, there may be suppuration (formation of pus), exfoliation (desquamation), and formation of granulation tissue.
Contributing factors, such as undercut height loss from poorly made or worn dentures, can sometimes be easily seen, resulting in mandibular overinversion (“jaw collapse”).
If there is a nutritional deficiency underlying the condition, various other signs and symptoms such as glossitis (swollen tongue) may be present.
In people with cheilosis who wear dentures, there can often be erythematous mucosa under the denture (usually the upper denture), an appearance consistent with denture-related stomatitis.
The lesions usually produce symptoms of pain, itching (itching), or a burning or raw sensation.
Causes of cheilosis
Cheilosis is believed to be a multifactorial disorder of infectious origin, with many local and systemic predisposing factors.
Sores in cheilosis are often infected with fungi (yeasts), bacteria, or a combination of these; this may represent a secondary, opportunistic infection by these pathogens.
Some studies have linked the initial appearance of cheilosis with nutritional deficiencies, especially of the B vitamins (B2-riboflavin) and iron (which causes iron deficiency anemia), which in turn can be evidence of malnutrition or malabsorption.
Cheilosis can be a manifestation of contact dermatitis, which is considered in two groups; irritable and allergic.
Infection
The organizations involved are:
Candida species alone (generally Candida albicans), accounting for about 20% of cases.
Bacterial species, either:
Staphylococcus aureus alone, accounting for about 20% of cases, β-hemolytic streptococci alone. These types of bacteria have been detected in between 8% and 15% of cases of cheilosis, but less frequently they occur in isolation.
Or a combination of the above organisms, (a polymicrobial infection) with about 60% of cases involving C. albicans and S. aureus.
Candida can be detected in 93% of cheilotic lesions. This organism is found in the mouth of about 40% of healthy people, and some consider it a normal commensal component of the oral microbiota.
However, Candida shows dimorphism, that is, a form of yeast that is believed to be relatively harmless and a form of pathogenic hyphae that is associated with invasion of host tissues.
The potassium hydroxide preparation is recommended by some to help distinguish between harmless forms and pathogenic forms, and thus highlight which cases of cheilosis are actually caused by Candida.
The mouth can act as a Candida reservoir that reinjects the sores into the corners of the mouth and prevents the sores from healing.
An injury caused by the recurrence of a latent herpes simplex infection can occur in the corner of the mouth. This is cold sores, and is sometimes called “simple angular herpes.”
A cold sore in the corner of the mouth behaves similarly to another part of the lips, and follows a pattern of vesicular formation (blister) followed by rupture that leaves a scab that resolves in about 7-10 days and reappears in the same place periodically, especially during periods of stress.
Instead of using antifungal creams, angular herpes simplex is treated in the same way as cold sores, with topical antiviral medications like acyclovir.
Irritation contact dermatitis
22% of cheilosis cases are due to irritants. Saliva contains digestive enzymes, which can have a degree of digestive action on tissues if left in contact.
The corner of the mouth is normally exposed to saliva more than any other part of the lips.
Lower facial height reduction (vertical dimension or facial support) is usually caused by edentulism (tooth loss) or by the use of old dentures that are worn or not optimally designed.
This results in an excessive closure of the jaw (collapse of the jaws), which softens the angled skin folds at the corners of the mouth, effectively creating an intertriginous skin fold.
The tendency for saliva to accumulate in these areas increases, constantly moistening the area, which can cause maceration of the tissue and favors the development of a fungal infection.
By contrast, it is rare in people who retain their natural teeth. Cheilosis is also commonly seen in denture wearers.
Reduction in the vertical dimension of the lower face is believed to be a contributing factor in up to 11% of older people with cheilosis and in up to 18% of people with dentures who have cheilosis.
The reduction in vertical dimension can also be caused by tooth migration, the use of orthodontic appliances, and elastic tissue damage caused by UV light exposure and smoking.
Habits or conditions that keep the corners of the mouth moist include chronic lip licking, thumb sucking (or other objects such as pens, pipes, lollipops), cleaning teeth (such as flossing), chewing gum , hypersalivation, drooling, and mouth breathing.
Some consider that licking or pricking the lips is a form of nervous tic, and do not consider it to be a true cheilosis, but call it perlèche (derived from the French word pourlècher which means “lick the lips”), or “artificial cheilitis” applies to this habit.
The term ‘cheilocandidiasis’ describes exfoliative (scaling) lesions on the lips and the skin around the lips, and is caused by a superficial yeast infection due to chronic lip licking.
Less severe cases occur during cold, dry weather, and it is a form of chapped lips.
Due to the delay in the onset of contact dermatitis and the recovery period that lasts from days to weeks, people generally do not make the connection between the causative agent and the symptoms.
Nutritional deficiencies
Several different states of nutritional deficiency of vitamins or minerals have been linked to cheilosis.
It is believed that in about 25% of people with cheilosis, iron deficiency or B vitamin deficiency are involved. L
Nutritional deficiencies may be a more common cause of cheilosis in Third World countries.
Chronic iron deficiency can also cause koilonychia (spoon-shaped deformity of the nails) and glossitis (inflammation of the tongue).
Vitamin B5 deficiency can also cause cheilosis, along with glossitis and skin changes similar to seborrheic dermatitis around the eyes, nose, and mouth.
Vitamin B12 deficiency is sometimes responsible for cheilosis, and it commonly occurs in conjunction with folate deficiency (a lack of folic acid), which also causes glossitis and megaloblastic anemia.
Vitamin B3 deficiency (pellagra) is another possible cause, and in which other conditions of association such as dermatitis, diarrhea, dementia and glossitis can occur.
Biotin (vitamin B7) deficiency has also been reported to cause cheilosis, along with hair loss (alopecia) and dry eyes. Zinc deficiency is known to cause cheilosis.
Other symptoms can include diarrhea, alopecia, and dermatitis. Acrodermatitis enteropathica is an autosomal recessive genetic disorder that causes impaired zinc absorption and is associated with cheilosis.
In general, these nutritional disorders can be caused by:
Malnutrition, as can occur in alcoholism or in poorly considered diets, or due to malabsorption secondary to gastrointestinal disorders.
For example, celiac disease or chronic pancreatitis or gastrointestinal surgeries, for example, pernicious anemia caused by ileal resection in Crohn’s disease.
Systemic disorders
Some systemic disorders are implicated in cheilosis by virtue of its association with malabsorption and the creation of nutritional deficiencies described above.
Such examples include people with anorexia nervosa. Other disorders can cause lip enlargement (for example, orofacial granulomatosis), which alters the local anatomy and softens the skin folds at the corners of the mouth.
Even more, they may be involved because they affect the immune system, allowing normally harmless organisms like Candida to become pathogens and cause an infection.
Xerostomia (dry mouth) is believed to account for about 5% of cheilosis cases. Xerostomia itself has many possible causes, but commonly the cause can be the side effects of medications or conditions such as Sjögren’s syndrome.
Conversely, conditions that cause drooling or hypersalivation (excessive salivation) can cause cheilosis by creating a constant moist environment at the corners of the mouth.
About 25% of people with Down syndrome appear to have cheilosis.
This is due to relative macroglossia, a seemingly large tongue in a small mouth, which can constantly protrude from the mouth causing the corners of the mouth to macerate with saliva.
Inflammatory bowel diseases (such as Crohn’s disease or ulcerative colitis) can be associated with cheilosis.
In Crohn’s disease , it is likely the result of malabsorption and immunosuppressive therapy that results in sores in the corner of the mouth.
Glucagonomas are rare pancreatic endocrine tumors that secrete glucagon and cause a syndrome of dermatitis, glucose intolerance, weight loss, and anemia. Angular cheilitis is a common feature of glucagonoma syndrome.
Rarely, cheilosis can be one of the manifestations of chronic mucocutaneous candidiasis, and sometimes oropharyngeal or esophageal candidiasis may accompany angular cheilitis.
Cheilosis can be present in human immunodeficiency virus infection, neutropenia, or diabetes. Cheilosis is more common in people with eczema because their skin is more sensitive to irritants.
Other possibly associated conditions include plasma cell gingivitis, Melkersson-Rosenthal syndrome, or sideropenic dysphagia (also called Plummer-Vinson syndrome or Paterson-Brown-Kelly syndrome).
Drugs
Various drugs can cause cheilosis as a side effect, by various mechanisms, such as the creation of drug-induced xerostomia. Several examples include isotretinoin, indinavir, and sorafenib.
Isotretinoin (Accutane), a vitamin A analog, is a drug that dries the skin.
Less commonly, cheilosis is associated with primary hypervitaminosis A, which can occur when:
Large amounts of liver are consumed regularly (including cod liver oil and other fish oils) or as a result of excessive consumption of vitamin A in the form of vitamin supplements.
Recreational drug users can develop cheilosis. Examples include cocaine, methamphetamines, heroin, and hallucinogens.
Allergic contact dermatitis
Allergic reactions can account for approximately 25-34% of cases of generalized cheilitis (that is, inflammation not limited to the corners of the mouth).
It is not known how often allergic reactions are responsible for cases of cheilosis, but any substance capable of causing generalized allergic cheilitis can occur only in the corners of the mouth.
Examples of potential allergens include substances that may be present in:
Some types of lipstick, toothpaste, acne products, cosmetics, chewing gum, mouthwash, foods, dental appliances, and denture materials or amalgam fillings that contain mercury.
It is generally impossible to tell the difference between irritant contact dermatitis and allergic contact dermatitis without a patch test.
Loss of lower facial height
Severe tooth wear or poorly fitting dentures can cause wrinkles at the corners of the lip that create a favorable environment for the condition.
This can be corrected with onlays or crowns on worn teeth to restore height or new dentures with “taller” teeth. Loss of vertical dimension has been associated with cheilosis in older people with increased facial laxity.
Diagnosis of cheilosis
Angular chielitis is generally a clinically made diagnosis. If the sore is unilateral, rather than bilateral, this suggests a local factor (eg, trauma) or a divided syphilitic papule.
Cheilosis caused by a jaw bandage, drooling, and other irritants is usually bilateral.
Lesions are normally cleaned to detect if Candida or pathogenic bacterial species may be present. People with cheilosis who wear dentures will often have their dentures cleaned as well.
A complete blood count (complete blood count) may be ordered, including assessment of levels of iron, ferritin, vitamin B12 (and possibly other B vitamins), and folate.
Classification of cheilosis
Cheilosis could be considered a type of cheilitis or stomatitis. When it comes to Candida species, angular cheilitis is classified as a type of oral candidiasis, specifically a primary lesion (group I) associated with Candida.
This form of cheilosis that is caused by Candida is sometimes called “Candida-associated angular cheilitis,” or less commonly, “perlèche monilial.”
Angular cheilitis can also be classified as acute (sudden, short-term onset of the disease) or chronic (lasts a long time or keeps coming back) or refractory (the condition persists despite attempts to treat it).
Treatment for cheilosis
There are 4 aspects to the treatment of angular cheilitis. First, potential reservoirs of infection within the mouth are identified and treated.
Oral candidiasis, especially denture-related stomatitis, is often present in cases of cheilosis, and if left untreated, sores at the corners of the mouth can recur frequently.
This means that dentures are properly fitted and disinfected.
Commercial preparations are marketed for this purpose, although dentures can be left in diluted household bleach (1:10 concentration) overnight, but only if they are completely plastic and contain no metal parts, and with clean water before use.
Greater denture hygiene is often required, including not wearing the denture during sleep and cleaning it daily. For more information, see Denture Related Stomatitis.
Second, there may be a need to increase the vertical dimension of the lower face to avoid excessive closure of the mouth and the formation of deep folds of the skin.
This may require the construction of a new denture with an adjusted bite.
On rare occasions, in cases resistant to normal treatments, surgical procedures such as collagen injections (or other facial fillers such as autologous fat or cross-linked hyaluronic acid) are used in an attempt to restore the normal facial contour.
Other measures that attempt to reverse local factors that may contribute to the condition include improving oral hygiene, stopping smoking or other tobacco habits, and using a barrier cream (eg, zinc oxide paste) at night.
Third, the treatment of infection and inflammation of the lesions themselves is addressed. This is usually with topical antifungal medications, such as clotrimazole, amphotericin B, ketoconazole, or nystatin cream.
Some antifungal creams are combined with corticosteroids like hydrocortisone or triamcinolone to reduce inflammation, and certain antifungals like miconazole also have some antibacterial action.
Diyodohydroxyquinoline is another topical therapy for angular cheilitis.
If Staphylococcus aureus infection is proven by microbiological culture as responsible (or suspected), treatment can be changed to fusidic acid cream, an antibiotic that is effective against this type of bacteria.
Aside from fusidic acid, neomycin, mupirocin, metronidazole, and chlorhexidine are alternative options in this scenario.
Finally, if the condition seems resistant to treatment, investigate the underlying causes, such as anemia or nutrient deficiencies or HIV infection.
Identifying the underlying cause is essential in treating chronic cases. Lesions may resolve when underlying disease is treated, eg. with a course of oral iron or vitamin B supplements.
Some recommend patch testing in cases that are resistant to treatment and where allergic contact dermatitis is suspected.
Prognosis for cheilosis
Most cases of cheilosis respond quickly when antifungal treatment is used.
In older cases, the severity of the condition often runs a relapsing and remitting course over time. The condition can be difficult to treat and can be prolonged.
Cheilosis epidemiology
Cheilosis is a relatively common condition, accounting for 0.7 to 3.8% of oral mucosa lesions in adults and 0.2 to 15.1% in children, although it generally occurs more frequently in adults in the third to sixth decades of life. life.
It occurs all over the world, and both men and women are affected. Cheilosis is the most common presentation of fungal and bacterial infections of the lips.
