Cheilosis treatment symptoms prevention Home remedies

In this article, we are going to learn about Angular Cheilosis symptoms and Angular Cheilosis treatment. It is also known as Angular Stomatitis or Perleche. Angular cheilitis is an inflammatory condition of the skin that causes red or grey-white colored patches or lesions at the angles of the mouth where the two lips meet It can occur on one or both sides of the mouth. It can last for just a few days, or it can result in chronic inflammation of the skin. And it can cause many other complications. It affects people of all ages including infants and older people.

Angular Cheilosis Symptoms

As the name of the disease suggests, the symptoms exclusively appear at the angles of the mouth. The symptoms can range from mild redness to open and bleeding blisters that can cause extreme pain and discomfort. If the person has Cheilosis, the corners of his mouth may show one or more of the following symptoms:

• Small lesions with grey-white thickened areas or red patches
• Maceration of the oral commissures
• Bleeding
• Burning sensation 
• Tenderness
• Redness
• Swelling
• Itchiness
• Pain
• Cracks
• Crustiness
• Scaling
• Blisters
• Lip Infection

The lips may feel dry and uncomfortable. Other symptoms include a bad sense of taste. If the pain and irritation are extreme, the person can not eat properly, and may not get enough calories, and will eventually lose weight.

Stage 1: Minor Angular Cheilosis:

Minor Angular Cheilitis is the first stage of this disease. It usually refers to the onset of angular Cheilosis. Minor Angular Cheilitis is characterized by small flaky skin at the corners of the mouth. When you are in this stage, you will also experience tightness at the corners of the mouth and slight discomfort whenever you try to open the mouth wide.

Stage 2: Mild Angular Cheilosis:

Mild Angular Cheilitis is the second stage of this disease. When you are suffering from mild Angular Cheilitis, you will start to notice discomfort and tightness in the corners of your mouth. You will also start seeing flaky skin and redness at the corners of the mouth. You feel uncomfortable whenever you try to open your mouth wide.

Stage 3: Severe Angular Cheilosis:

Severe Angular Cheilitis is the third stage of this disease. This stage is characterized by pain and discomfort whenever you try to talk, eat or do anything else that requires you to open your mouth. It will be easy for you and others to notice the lesions in the corners of your mouth. Neosporin, chapstick, and other ointments that are usually used to heal Angular Cheilitis will not work.

Stage 4: Chronic Angular Cheilitis:

Chronic Angular Cheilitis is the fourth and the last stage of this disease. When you are suffering from Chronic Angular Cheilitis, you will heal over several months but the symptoms will come back again. Dryness and cracks as a result of Angular Cheilitis will always cause severe discomfort and pain. It is the worst form of angular cheilitis.

Causes of Angular Cheilosis

The most common cause of Cheilosis is the infection by the yeast. The saliva builds up and collects at the corners of the mouth. When it dries, the skin in this area gets cracked. The person licks the cracked skin to ease the distress. The warmth and humidity created at the angles of the mouth provide a favorable environment for the fungus to grow and cause infection. Certain bacterial species such as staphylococcus aureus and β-hemolytic streptococci can also cause angular cheilitis. Sometimes, both the fungi and the bacteria are responsible for the disease. It is known as polymicrobial infection.

Other Causes of Angular Cheilitis include:

• Regular oral thrush
• Nervous tics such as over-licking of lips
• Excess use of corticosteroids or antibiotics
• Use of oral retinoid medications
• Aggressive dental flossing
• Thumb-sucking
• Drooling or hypersialia
• Sensitive Skin
• An overhang of the upper lip, creating deeper angles at the corners of the lips
• Smoking
• Certain medical conditions like anemia, diabetes, or cancer
• Deficiencies of vitamins B-9, B-6, B-2, or B-3, or the mineral zinc
• Other inflammatory illnesses, such as Crohn’s disease

Sometimes, the cause of Cheilosis is unknown. This is known as idiopathic angular cheilitis or Cheilosis.

Angular cheilitis Risk factors

Certain people have more chances of developing angular stomatitis. The risk factors responsible for this are

Excessive saliva

Some people secrete excessive saliva, and when it comes in contact with the skin around the angles of the mouth, it provides a convenient environment for the microorganisms to cause infection. Also, some people are habitual of frequent lip-licking; this moistens the corners of the mouth. Some people have a specific shape of lips and the mouth, this can cause accumulation of the saliva around the edges of the mouth. People whose upper lip hangs over the lower lip also face the same problem and develop angular stomatitis or Cheilosis frequently.

Immunocompromised state

A weak immune system allows the microorganisms to grow efficiently and cause Cheilosis. There are many causes of a compromised immune system. The most essential reason is AIDS, in which the virus attacks the helper T cells making the person immunocompromised. The patients taking chemotherapeutic drugs for cancer treatment also have a fragile immune system, making them vulnerable to angular stomatitis. Some diseases require continuous administration of steroids. They work by suppressing the immune response. So, these patients are at constant risk of developing angular cheilitis. Some antibiotics also have the same effect as steroids.

Genetics

Different studies have shown that genetics plays a vital role in angular Cheilosis. Down’s syndrome, which is due to the trisomy of chromosome number twenty one, is a known risk factor of developing angular cheilitis. (Christensen n.d.)

Nutritional deficiency

Lack of certain nutrients in the diet makes a person vulnerable to developing angular cheilitis. Many studies have shown that the deficiency of iron and vitamin B2 can increase the chances of developing angular cheilitis. A survey conducted by N C Murphy titled ” Iron deficiency: an overlooked predisposing factor in angular cheilitis ” provides substantial evidence of the importance of these micronutrients in Cheilosis . (“Iron Deficiency: An Overlooked Predisposing Factor in Angular Cheilitis” 1979)

Oral thrush

Having regular oral thrush is a significant risk factor behind angular cheilitis. Oral thrush happens when a yeast infection develops inside your mouth. This enables the yeast to inhabit the moist environment around the corner of the mouth quickly, thus causing angular cheilitis.

Dentures

Wearing braces or dentures that are not fitting correctly allows the saliva to drip and collect easily around the angles of the lips. This enhances the chances of the fungus to grow and cause angular stomatitis. 

Dry lips

Having parched lips cause them to crack easily. This makes viruses, bacteria, and yeast to invade easily.

Sensitive skin

The persons having sensitive skin are more exposed to be infected by bacteria, yeast, and viruses, thus causing Cheilosis.

Retinoids

The use of oral retinoid medication for certain skin diseases increases the chances of developing Cheilosis .

Autoimmune diseases

Some autoimmune diseases like Crohn’s disease and Sjogren’s syndrome also cause Cheilosis as a part of their systemic manifestation.

Certain medical conditions can put you at a higher risk of getting Cheilosis. These include diabetes, kidney, liver, lung, pancreatic, and blood cancer.

Smoking

Smoking is a risk factor for several diseases ranging from an uncomplicated ulcer to complex diseases such as cancer. Many studies have linked tobacco as one of the leading causes of angular stomatitis or Cheilosis . A study titled ” Effect of long term smoking on whole mouth salivary flow rate and oral health ” showed that smoking significantly reduces the salivary flow rate, and increase oral and dental disorders. Smoking causes the lips and the oral cavity to dry up, and it also impairs the healing process. All of this is responsible for causing angular stomatitis. (Rad et al. 2010) 

Cheilosis and diabetes

Diabetes is a systemic disease involving many organs of the body at the same time. Many studies have shown that diabetic people are more prone to fungal infections like oral thrush, vaginal thrush, and angular cheilitis—a study conducted by Awatif Y. Al Maskari titled ” Oral manifestations and complications of diabetes mellitus” stated that fungal infections occur more frequently in people with diabetes. This is because the fungi use glucose to grow and reproduce. People having diabetes have too much glucose in their blood, making it easier for the fungi to cause the disease. Moreover, diabetes weakens the immune system of the body. This makes it even harder for the body to fight against infections.

This can be prevented by keeping the blood glucose levels within the normal range. Try to eat a healthy diet devoid of sugar and fats. Exercise is essential in controlling the blood sugar level. Finally, taking insulin as prescribed by the doctor can prevent diabetes from causing severe complications. (Al-Maskari, Al-Maskari, and Al-Sudairy 2011)

Pathophysiology

Most cases of angular cheilitis are due to the softening of the angles of the mouth due to overexposure of the saliva. The digestive enzymes present in the saliva can act on the body tissues if allowed prolonged contact. Continuous exposure of the saliva induces inflammation around the corners of the mouth. The integrity of the skin becomes compromised and allows fungi and bacteria to cause infection. 

Cheilosis  Diagnosis

Cheilosis an be diagnosed quickly based on history, clinical examination, and laboratory investigations.

History

The following questions are asked to the patient to evaluate the risk factors responsible for angular cheilitis.

• Ask the patient if he wears any braces or dentures, and also if the size is appropriate or not. Poorly fitted dentures can cause wrinkles at the angles of the mouth. This causes the saliva to collect, thus, creating a favourable environment for the microorganisms to cause the disease.
• Does the patient tend to lick the angles of the mouth?
• Does the patient have a burning sensation inside the lips or altered sensation of taste? If yes, then this is a sign of underlying fungal or bacterial infection.
• Ask the patient about any medications taken recently. Certain medications like steroids, chemotherapeutic drugs, and some antibiotics weaken the immune response and increase the chances of acquiring the disease.
• Ask the patient about any underlying genetic, autoimmune, or other systemic diseases.
• Ask the patient about any history of smoking.

Cheilosis Clinical examination

Upon clinical examination, the doctor might see the following changes around the angles of the mouth.

• Redness
• Swelling
• Blisters
• Cracks
• Crusts

All these changes are indicative of the underlying disease. The doctor might also see the signs of other systemic illnesses which are involved in causing angular cheilitis.

Laboratory investigation

To confirm the diagnosis, and to rule out the exact cause of the disease, a sample is taken from the corners of the mouth using a swab. It is then sent to the laboratory for thorough cytological analysis and tissue culture. This confirms whether the bacteria or yeast causes the disease.

Cheilosis Treatment

The Cheilosis treatment depends upon the underlying cause. Firstly, it is crucial to evaluate local predisposing factors that include

• Evaluation of prosthetic implants
• Maintenance of good oral hygiene
• Hygiene of prosthetic implants
• Local salivary glands issues

Moreover, the angular cheilitis can be treated in the following ways.

Diet and lifestyle

Angular cheilitis treatment will depend on if underlying cause of the disease is poorly controlled diabetes mellitus, then certain modifications in the diet and lifestyle can help treat the condition. The dietary changes include eating foods without sugar and fats. Lifestyle can be improved by engaging yourself in healthy activities like running, jogging, and swimming. Finally, glucose-lowering drugs and insulin can help control blood sugar levels.

If the underlying cause is the deficiency of iron and vitamin B2, then the supplements are recommended to overcome the lack of these nutrients. Also, foods rich in these nutrients such as dark leafy greens vegetables like spinach, beans, lentils, whole grains, cereals, and liver are recommended.

Antifungal and antibacterial medications

If the laboratory analysis confirms that the cause of the disease is a fungal infection, then topical antifungal medications are prescribed. Some of them include

• Nystatin
• Clotrimazole
• Miconazole
• Ketoconazole

Mostly the fungus involved in the disease is candida which response to these topical agents.

In the case of bacterial infection, topical antibacterial medications are used. These include

• Mupirocin
• Bacitracin

Usually, a combination of topical antifungal, antibacterial, and glucocorticoid ointment such as Viaderm-K.C. is advised by the doctor for cheilosis treatment. It is applied as a thin layer three times daily for fourteen days.

If an intraoral fungal infection is present, then systemic antifungal therapy is started.

Drugs that are used in the USA to treat Angular Cheilitis:

Topical treatment:

• Miconazole Nitrate (2%)
• Fuscidin cream

Oral Treatment:

• Nystex
• Nystop
• Sporanox

Drugs that are used in EU to treat Angular Cheilitis:

Topical treatment:

• Daktarin ® cream (miconazole) may be preferable as it treats candida, as well as having some Gram‐positive bacteriostatic action
• If the skin is significantly inflamed consider a topical steroid combination product eg Daktacort ® cream (miconazole plus 1% hydrocortisone), or, the short-term use of Trimovate ® cream
• If the skin is not improving and swabs show staphylococcal infection, treat with Fucidin ® cream (fusidic acid) or Fucidin H ® cream (also contains 1% hydrocortisone) at least 4 times a day.

For Oral Treatment:

• Mycostatin
• Itraconazole (100mg caps)
• Sporanox

Hygiene

Keeping the area around the mouth clean and dry can ease up the pain and prevent the infection from worsening. A lip balm or petroleum jelly can prevent the lips from becoming dehydrated. It can also inhibit the formation of crusts. For cheilosis treatment The doctor usually recommends a topical steroid cream. It can reduce pain and itching, and can also stimulate healing of the damaged skin.

Fillers and injections

When Cheilosis is caused by an abnormal shape of the lips or the mouth, or if a person is affected by angular cheilitis many times, a doctor might advise treatment to change the shape of the mouth. Cosmetic fillers are used for this purpose. The injection applies them. They significantly improve the shape of the hanging lips that can cause angular cheilitis.

Optimal Therapeutic Approach:

Treatment of angular cheilitis should be customized to address the suspected cause/causes of this multifactorial condition in the individual patient. For each case, it is helpful to determine if the condition is likely due to mechanical factors alone or due to a combination of local factors and yeast and/or bacterial overgrowth.

Perform careful dietary history and review of symptoms. If concerned about the possibility of nutritional deficiency, check complete blood count (CBC), reticulocyte count, iron, B2, B9, B12, and zinc levels. Angular cheilitis that is secondary to the nutritional deficiency will improve with appropriate nutritional supplementation.

If physical and behavioral factors (thumb sucking, lip licking, aggressive dental floss use) are suspected as the etiology, consider frequent emollient or barrier paste application and behavioral modification as initial therapy.

If the cause of angular cheilitis is bacteria or fungi, then treat it as described above.

Patient Management:

Due to the multifactorial nature of this condition, patients should have a follow-up visit in 2-3 weeks after initiation of therapy to determine if their treatment regimen should be adjusted. Given that chronic local factors often contribute to the development of angular cheilitis, the condition will likely recur.

In patients with dentures or anatomical changes predisposing them to recurrent episodes of angular cheilitis, optimization of dental hygiene (including denture fit and cleaning) and frequent application of barrier paste or emollient (zinc oxide, petrolatum, lip balm) seem to be reasonable but unproven prevention strategies. In patients with significant impairment from recurrent angular cheilitis flares in the context of anatomical distortion, injection of filler material or oral surgery to restore anatomy should be considered. Physicians should monitor patients who are chronically affected by angular cheilitis for weight loss and nutritional deficiencies that may develop from decreased food intake secondary to pain from the condition

Follow up

For Successful cheilosis treatment Follow up is usually recommended at two weeks. If the condition is resolved, then continue monitoring. If the situation is not settled, then an appropriate systemic antifungal therapy is recommended.

If systemic illnesses are suspected as a cause of the disease, then the patient must be referred to the concerned specialist for further management of the disease.

Complications

Longstanding and untreated Angular Cheilosis can cause many complications such as:

• Tissue atrophy
• Permanent scarring
• Permanent discoloration
• Severe weight loss due to difficulty in eating
• Infections by other bacteria and viruses

The pathogens that cause angular cheilosis, if left untreated, can cause many other diseases. For example, Candida Albicans can cause vaginal thrush, athlete’s foot, ear infection, and wound infection. Staphylococcus aureus that causes angular cheilitis, if left untreated, can cause pneumonia, meningitis, osteomyelitis, endocarditis, toxic shock syndrome, bacteremia, and sepsis.

The systemic diseases that can cause angular stomatitis have complications of their own. For example, if diabetes is not treated well, it can cause heart problems, stroke, chronic renal failure, diabetic foot, and severe neuropathy.

When to see a doctor

Cheilosis is not a life-threatening disease. It is easy to treat, but it doesn’t mean that it should be treated at home. Always consult your doctor to rule out the cause of the disease. People who experience red spots or bleeding on the edges of their lips, or who experience lip pain, burning, dryness, or crusts should get themselves checked by the doctor. Early treatment by the doctor can prevent the spread of the infection and the development of complications.

Cheilosis Prevention

Angular cheilitis can be prevented by taking the following measures.

• Avoid unnecessary licking of the lips, and try to keep them dry.
• Use a moisturizing lip balm that provides protection against UV rays and prevents the lips from becoming dry and cracked.
• Eat a diet that is rich in vitamin B, iron, and folic acid.
• Always try to wear dentures of the size that fits you.

Cheilosis is not a dangerous disease, and is easily treatable by following guideline for Angular cheilitis treatment, once the diagnosis is made on time by the concerned doctor. The symptoms usually improve within a few days of starting the Cheilosis treatment . It can be painful and inconvenient for the patient. It is easily preventable by following simple steps. Some people get Cheilosis again and again. This is because of the persistence of the risk factors. By making simple changes in the lifestyle, you can get rid of the Angular cheilitis.

Home Remedies for the treatment of Angular Cheilosis:

Salt Water

Things that you need:

• 1/2 Teaspoon salt
• 3/4 Cup of lukewarm water
• Clean washcloth or cotton balls

What you need to do:

• Mix ½  teaspoon of table salt to three-fourths cup of slightly warm water.
• Mix it well and soak a clean washcloth or cotton ball.
• Place the soaked cotton ball / washcloth in the affected corners of your lips.
• Let it there for 10 to 15 minutes.
• Rinse your lips with salt water.
• Do this process three times regularly.

This is how it works: This remedy may initially burn, but should be tried. The natural antiseptic properties of salt help to reduce infection and prevent it from developing

Apple Cider Vinegar

Things that you need:

• 1 tablespoon apple cider vinegar
• 3/4^th Cup of water
• Cotton grains

What you need to do:

• Add one tablespoon apple cider vinegar to three-quarters cup water.
• Dip one end of a cotton ball into warm paraffin 3 times, pausing between layers to allow them to dry.
• Leave  on for 15 to 20 minutes.
• Cleanse it from the skin.
• Repeat once every 4 to 5 hours.

This is how it works: Apple cider vinegar exhibits powerful antibacterial and antifungal activity, both of which are excellent at removing germs that cause angular Cheilosis. The anti-inflammatory properties of Apple cider vinegar relieve your irritated skin.

Coconut Oil

Things that you need:

1-2 tablespoons cold pressed coconut oil

What you need to do:

• Apply coconut oil directly on the affected areas.
• Leave it there for 30 to 40 minutes before rinsing.
• Reapply as needed.

This is how it works: Coconut oil demonstrates two main benefits in treating angular Cheilosis. One is the antifungal properties that can fight the growth of fungus in your mouth, and the second is the moisturizing properties that prevent further damage to your lips.

Lemon

Things that you need:

• ½ Lemon
• 1 glass of water
• Honey (on demand)

What you need to do:

• Add juice of ½ lemon to a glass of water.
• Stir well and add a little honey.
• Drink with straw.

This is how it works: Drinking lemon juice 2 to 3 times a day after the onset of angular Cheilosis can help you recover faster from it. The presence of vitamin C in lemon boosts the natural immune system, which can help cure your condition.

Jojoba oil

Things that you need:

A few drops of jojoba oil

What you need to do:

• Apply a few drops of jojoba oil directly on the affected area.
• Leave on for 20 to 30 minutes before rinsing in water.
• Repeat three times.

This is how it works: Jojoba oil is very moisturizing and protects your lips from dryness, itching and swelling.

Baking Soda

Things that you need:

• 1 tablespoon baking soda
• water
• Clean cloth
• Moisturizer

What you need to do:

• Add a tablespoon of baking soda to a little water in a cup.
• Apply the paste on the affected areas.
• Allow this to sit for about 5 minutes.
• Dry your mouth with a clean towel and apply with a moisturizer.
• Repeat this after 3 to 4 hours.

This is how it works: Baking soda has natural antiseptic properties that help eliminate bacterial infections such as angular Cheilosis.

Lavender Oil

Things that you need:

• 2-3 drops of lavender oil
• 2 tablespoons coconut oil
• Cotton

What you need to do:

• Add lavender oil to coconut oil.
• Dip a cotton ball into the mixture.
• Apply on the affected area.
• Repeat after 3 or 4 hours.

This is how it works: Lavender oil exhibits antifungal action, which helps to easily combat angular chilitis. This essential oil is anti-inflammatory and analgesic, relieving inflammation and itching.

Garlic

Things that you need:

• 2 chopped garlic cloves
• Moisturizer

What you need to do:

• Take two garlic cloves and crush them.
• Apply garlic paste directly on the affected area and leave on for 5 to 10 minutes.
• Clean the mixture from the skin.
• Moisturize the area.
• Repeat every 4 hours.

This is how it works: Garlic contains a compound called allicin, which has an antiseptic action. Topical application of garlic is excellent for the treatment of angular Cheilosis and its associated itching and inflammation.

Honey

Things that you need:

• 1 tablespoon honey

What you need to do:

• Apply honey on the affected areas around your mouth.
• Leave on for 15 to 30 minutes.
• Rinse with honey and let the skin dry.
• Do this twice every 3 or 4 hours.

This is how it works Honey is an excellent remedy for angular Cheilitis due to its antifungal and antiseptic properties.

Petroleum Jelly

Things that you need:

• Petroleum jelly

What you need to do:

• Take a little petroleum jelly and apply on the affected skin.
• Reapply when needed.

This is how it works: The strong emollient action of petroleum jelly helps to moisturize the affected area. It helps to speed up the healing of angular chilitis.

Tea Tree oil

Things that you need:

• 2-3 drops of tea tree oil
• 2 tablespoons coconut oil
• Cotton

What you need to do:

• Add two to three drops of tea tree oil in two teaspoons of coconut oil and mix well.
• Apply it gently to the corners of your mouth.
• Repeat after 3 hours.

This is how it works: Tea tree oil has antifungal properties that help suppress fungal growth, while at the same time reducing inflammation and pain caused by inflammation.

Yogurt

Things that you need:

• 1-2 tablespoons plain yogurt

What you need to do:

• Apply some yogurt to the affected corners of your mouth.
• Leave it there for overnight.
• You can also eat a small bowl of yogurt.

This is how it works: The probiotic yogurt is used for the treatment of angular chilitis as topical application and for consumption as a food. It prevents inflammation of the corners of the mouth and moisturizes the skin.

Aloe Vera Gel

Things that you need:

• 1-2 tablespoons of freshly squeezed aloe vera gel

What you need to do:

• Freeze two teaspoons of aloe vera gel.
• Apply cold gel on the affected skin.
• Leave on for 20 to 30 minutes before washing.
• Repeat every 3 or 4 hours.

This is how it works: Aloe vera gel has healing properties. It helps to soothe irritated skin and prevents further infections with natural antifungal action.

Neem Oil

Things that you need:

• 2-3 drops of neem oil

What you need to do:

• Take a few drops of neem oil and apply it directly on the skin.
• Leave on for 30 to 40 minutes.
• Rinse it off with water and let the skin dry.
• Do 2 to 3 times regularly.

This is how it works: Neem oil is very useful in treating skin conditions like angular chilitis due to its antifungal action. It also eliminates the inflammation and pain that usually accompanies this fungal condition.

Listerine

Things that you need:

• Listerine
• Cotton ball

What you need to do:

• Take some quantity of Listerine in a bowl.
• Dip a cotton ball in the Listerine solution.
• Apply the Listerine solution on the affected area.
• Leave it for 15-20 minutes.
• Rinse it off with cold water.
• Repeat using the Listerine solution for 1 week by applying for 2-3 times in a day.

This is how it works: It is a mouth wash that has many antifungal and antibacterial properties. It is a very effective treatment for Angular cheilitis.

Castor Oil

Things that you need:

• You can either use castor oil alone or can mix it with other essential oils.
• Mix ½ teaspoon of castor oil along with 2-3 drops of tea tree oil.

What you need to do:

• Take the mixture of tea tree oil and castor oil in a bowl.
• Take a cotton bowl and use it for applying the oil mixture on the affected parts.
• Leave the oil for about 30 minutes.
• Rinse the oil with cold water.
• Repeat the process twice in a day for getting the best solution.

This is how it works: Castor oil does not have any side effects on the skin unless you are allergic to it. Rather it acts as a dry corner of mouth remedy as it overcomes the dryness caused by angular cheilitis quite quickly. It is one of the most effective remedies for angular cheilitis as it helps in reducing the pain along with reducing the dryness of the skin. The strong anti-bacterial properties of castor oil help in reducing the infection around the affected area and thus become one of the best home remedies for angular cheilitis.

Castor oil is sufficient on its own for fighting against the problem of infections and thus can be used all alone. However, you can add other suitable oils in it, if you want to enhance its power to fight angular cheilitis.

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