«Մասնակից:Angela Aghasi/Ավազարկղ»–ի խմբագրումների տարբերություն
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Պիտակներ՝ Դատարկում Վիզուալ խմբագրիչն անջատված է |
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{{Infobox medical condition (new)
| name = Angular cheilitis
| image = Angular cheilitis1.jpg
| caption = Bilateral angular cheilitis in an elderly individual with false teeth, iron deficiency [[anemia]] and [[xerostomia|dry mouth]]
| pronounce = {{IPAc-en|k|aɪ|ˈ|l|aɪ|t|ɪ|s}}
| field = [[Dermatology]]
| synonyms = [[Rhagades]],<ref name="Pindborg1973">{{cite book|last=Pindborg|first=Jens Jørgen|title=Atlas of Diseases of the Oral Mucosa|url=https://books.google.com/books?id=3DFsAAAAMAAJ|accessdate=17 September 2014|year=1973|publisher=Saunders|isbn=9780721672649|quote=Angular cheilosis: The lateral lip fissures, well known among denture wearers, have been called by a variety of names, such as "rhagades", "perleche", "angular cheilitis", and "angular cheilosis".|url-status = live|archiveurl=https://web.archive.org/web/20170910173629/https://books.google.com/books?id=3DFsAAAAMAAJ|archivedate=10 September 2017|df=}}</ref> perlèche,<ref name=Park2011P1/> cheilosis,<ref name=Park2011P1/> angular cheilosis,<ref name=Park2011P1/> commissural cheilitis,<ref name=Park2011P1/> angular stomatitis<ref name=Park2011P1/>
| symptoms = [[erythema|Redness]], skin breakdown and crusting at the corner of the mouth<ref name=Park2011P1/>
| complications =
| onset = Children, 30s to 60s<ref name=Park2011P1 />
| duration = Days to years<ref name=Park2011P1/>
| types =
| causes = [[Infection]], irritation, [[allergies]]<ref name=Park2011P1/>
| risks =
| diagnosis =
| differential =
| prevention =
| treatment = Based on cause, [[barrier cream]]<ref name=Park2011P1/>
| medication =
| prognosis =
| frequency = 0.7% of the population<ref name=Lyon/>
| deaths =
}}
<!-- Definition and symptoms -->
'''Angular cheilitis''' ('''AC''') is [[inflammation]] of one or both corners of the [[mouth]].<ref name="Scully 2008">{{cite book|last=Scully|first=Crispian|title=Oral and maxillofacial medicine : the basis of diagnosis and treatment|year=2008|publisher=Churchill Livingstone|location=Edinburgh|isbn=9780443068188|edition=2nd|pages=147–49}}</ref><ref name=Park2011P2>{{cite journal|last=Park |first=KK |author2=Brodell RT |author3=Helms SE. |title=Angular cheilitis, part 2: nutritional, systemic, and drug-related causes and treatment |journal=Cutis |date=July 2011 |volume=88 |issue=1 |pages=27–32 |pmid=21877503 |url=http://www.skinandallergynews.com/fileadmin/qhi_archive/ArticlePDF/CT/088010027.pdf |url-status = dead|archiveurl=https://web.archive.org/web/20140419015237/http://www.skinandallergynews.com/fileadmin/qhi_archive/ArticlePDF/CT/088010027.pdf |archivedate=2014-04-19 }}</ref> Often the corners are [[erythema|red]] with skin breakdown and crusting.<ref name=Park2011P1/> It can also be itchy or painful.<ref name=Park2011P1/> The condition can last for days to years.<ref name=Park2011P1>{{cite journal|last=Park|first=KK|last2=Brodell |first2=RT |last3=Helms |first3=SE|title=Angular cheilitis, part 1: local etiologies|journal=Cutis |date=June 2011|volume=87|issue=6|pages=289–95|pmid=21838086}}</ref> Angular cheilitis is a type of [[cheilitis]] (inflammation of the lips).<ref>{{cite book|last1=Martin|first1=Elizabeth|title=Concise Medical Dictionary|date=2015|publisher=Oxford University Press|isbn=9780199687817|page=136|url=https://books.google.ca/books?id=wb26BwAAQBAJ&pg=PA136|language=en|url-status = live|archiveurl=https://web.archive.org/web/20160816060011/https://books.google.ca/books?id=wb26BwAAQBAJ&pg=PA136|archivedate=2016-08-16|df=}}</ref>
<!-- Cause and diagnosis -->
Angular cheilitis can be caused by [[infection]], irritation, or [[allergies]].<ref name=Park2011P1/> Infections include by [[fungi]] such as ''[[Candida albicans]]'' and [[bacteria]] such as ''[[Staph. aureus]]''.<ref name=Park2011P1/> Irritants include poorly fitting [[dentures]], licking the lips or drooling, mouth breathing resulting in a dry mouth, sun exposure, overclosure of the mouth, [[smoking]], and minor trauma.<ref name=Park2011P1/> Allergies may include substances like toothpaste, makeup, and food.<ref name=Park2011P1/> Often a number of factors are involved.<ref name=Park2011P1/> Other factors may include poor nutrition or [[immunosuppression|poor immune function]].<ref name=Park2011P1/><ref name=Park2011P2/> Diagnosis may be helped by testing for infections and [[patch testing]] for allergies.<ref name=Park2011P1/>
<!-- Treatment and epidemiology -->
Treatment for angular cheilitis is typically based on the underlying causes along with the use of a [[barrier cream]].<ref name=Park2011P1/> Frequently an [[antifungal cream|antifungal]] and [[antibacterial cream]] is also tried.<ref name=Park2011P1/> Angular cheilitis is a fairly common problem,<ref name=Park2011P1 /> with estimates that it affects 0.7% of the population.<ref name=Lyon>{{cite book|last1=Lyons|first1=Faye|title=Dermatology for the Advanced Practice Nurse|date=2014|publisher=Springer Publishing Company|isbn=9780826136442|page=95|url=https://books.google.ca/books?id=ns35AwAAQBAJ&pg=PA95|language=en|url-status = live|archiveurl=https://web.archive.org/web/20160816021841/https://books.google.ca/books?id=ns35AwAAQBAJ&pg=PA95|archivedate=2016-08-16|df=}}</ref> It occurs most often in the 30s to 60s, although is also relatively common in children.<ref name=Park2011P1 /> In the [[developing world]], [[iron deficiency|iron]] and [[vitamin deficiencies]] are a common cause.<ref name=Park2011P2/>
==Signs and symptoms==
[[File:Angular Cheilitis 2.jpg|thumbnail|Angular cheilitis – a fissure running in the corner of the mouth with reddened, irritated facial skin adjacent.]]
[[FIle:Angular Cheilitis.JPG|thumb|A fairly mild case of angular cheilitis extending onto the facial skin in a young person (affected area is within the black oval).]]
Angular cheilitis is a fairly non specific term which describes the presence of an inflammatory lesion in a particular anatomic site (i.e. the corner of the mouth). As there are different possible causes and contributing factors from one person to the next, the appearance of the lesion is somewhat variable. The lesions are more commonly symmetrically present on both sides of the mouth,<ref name="Scully 2008" /> but sometimes only one side may be affected. In some cases, the lesion may be confined to the mucosa of the lips, and in other cases the lesion may extend past the [[vermilion border]] (the edge where the lining on the lips becomes the skin on the face) onto the facial skin. Initially, the corners of the mouth develop a gray-white thickening and adjacent [[erythema]] (redness).<ref name=Park2011P1 /> Later, the usual appearance is a roughly triangular area of erythema, [[edema]] (swelling) and [[Cutaneous condition#Secondary lesions|breakdown of skin]] at either corner of the mouth.<ref name=Park2011P1 /><ref name="Scully 2008" /> The mucosa of the lip may become [[Skin fissure|fissured]] (cracked), crusted, [[mouth ulcer|ulcerated]] or [[Atrophy|atrophied]].<ref name=Park2011P1 /><ref name="Scully 2008" /> There is not usually any bleeding.<ref name="Wood 1997">{{cite book|author1=Wood, NK |author2=Goaz, PW |title=Differential diagnosis of oral and maxillofacial lesions|year=1997|publisher=Mosby|location=St. Louis [u.a.]|isbn=978-0815194323|pages=64–65, 85|edition=5th}}</ref> Where the skin is involved, there may be radiating [[rhagades]] (linear fissures) from the corner of the mouth. Infrequently, the [[dermatitis]] (which may resemble [[eczema]]) can extend from the corner of the mouth to the skin of the cheek or chin.<ref name="Scully 2008" /> If ''Staphylococcus aureus'' is involved, the lesion may show golden yellow crusts.<ref name="Coulthard 2008">{{cite book|vauthors=Coulthard P, Horner K, Sloan P, Theaker E |title=Master dentistry volume 1, oral and maxillofacial surgery, radiology, pathology and oral medicine|year=2008|publisher=Churchill Livingstone/Elsevier|location=Edinburgh|isbn=9780443068966|pages=180–81|edition=2nd}}</ref> In chronic angular cheilitis, there may be suppuration ([[pus]] formation), exfoliation (scaling) and formation of [[granulation tissue]].<ref name=Park2011P1 /><ref name="Scully 2008" />
Sometimes contributing factors can be readily seen, such as loss of lower face height from poorly made or worn dentures, which results in mandibular overclosure ("collapse of jaws").<ref name="Bruch 2010" /> If there is a nutritional deficiency underlying the condition, various other signs and symptoms such as glossitis (swollen tongue) may be present.<!-- <ref name="Scully 2008" /> --> In people with angular cheilitis who wear dentures, often there may be erythematous mucosa underneath the denture (normally the upper denture), an appearance consistent with denture-related stomatitis.<ref name="Scully 2008" /> Typically the lesions give symptoms of soreness, pain, [[pruritus]] (itching) or burning or a raw feeling.<ref name=Park2011P1 /><ref name="Bruch 2010" />
== Causes ==
Angular cheilitis is thought to be multifactorial disorder of infectious origin,<ref name="Soames 1999" /> with many local and systemic predisposing factors.<ref name="Tyldesley 2003" /> The sores in angular cheilitis are often infected with [[fungus|fungi]] (yeasts), [[bacteria]], or a combination thereof;<ref name="Coulthard 2008" /> this may represent a [[secondary infection|secondary]], [[opportunistic infection]] by these [[pathogen]]s. Some studies have linked the initial onset of angular cheilitis with nutritional deficiencies, especially of the B(B2-riboflavin) vitamins and iron (which causes [[iron deficiency anemia]]),<ref>{{cite web | author=MedlinePlus | title=Riboflavin (vitamin B<sub>2</sub>) deficiency (ariboflavinosis) | url=https://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-riboflavin.html | publisher=[[National Institutes of Health]] | date=2005-08-01 |url-status = live| archiveurl=https://web.archive.org/web/20100724032458/http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-riboflavin.html | archivedate=2010-07-24 | df= | author-link=MedlinePlus }}</ref> which in turn may be evidence of malnutrition or malabsorption. Angular cheilitis can be a manifestation of [[contact dermatitis]],<ref name=schalock265/> which is considered in two groups; irritational and allergic.
===Infection===
The involved organisms are:
* [[Candida (genus)|Candida]] species alone (usually ''[[Candida albicans]]''), which accounts for about 20% of cases,<ref name="Neville 2001" />
* Bacterial species, either:
** ''[[Staphylococcus aureus]]'' alone, which accounts for about 20% of cases,<ref name="Neville 2001" />
** [[Streptococcus#Beta-hemolytic|β-hemolytic streptococci]] alone. These types of bacteria have been detected in between 8–15% of cases of angular cheilitis,<ref name=Park2011P1 /> but less commonly are they present in isolation,<ref name="Soames 1999" />
* Or a combination of the above organisms, (a polymicrobial infection)<ref name="Coulthard 2008" /> with about 60% of cases involving both ''C. albicans'' and ''S. aureus''.<ref name="Neville 2001" /><ref name="Kerawala 2010">{{cite book|editor=Kerawala C |editor2=Newlands C |title=Oral and maxillofacial surgery|year=2010|publisher=Oxford University Press|location=Oxford|isbn=9780199204830|page=446}}</ref>
Candida can be detected in 93% of angular cheilitis lesions.<ref name=Park2011P1 /> This organism is found in the mouths of about 40% of healthy individuals, and it is considered by some to be normal commensal component of the oral [[Skin microbiota|microbiota]].<ref name=Park2011P1 /> However, Candida shows dimorphism, namely a yeast form which is thought to be relatively harmless and a [[pathogenic]] [[hypha]]l form which is associated with invasion of host tissues. [[Potassium hydroxide]] preparation is recommended by some to help distinguish between the harmless and the pathogenic forms, and thereby highlight which cases of angular cheilitis are truly caused by Candida.<ref name=Park2011P1 /> The mouth may act as a reservoir of Candida that reinfects the sores at the corners of the mouth and prevents the sores from healing.
A lesion caused by recurrence of a latent [[herpes simplex]] infection can occur in the corner of the mouth. This is [[herpes labialis]] (a cold sore), and is sometimes termed "angular herpes simplex".<ref name=Park2011P1 /> A cold sore at the corner of the mouth behaves similarly to elsewhere on the lips, and follows a pattern of [[Vesicle (dermatology)#Primary lesions|vesicle]] (blister) formation followed by rupture leaving a crusted sore which resolves in about 7–10 days, and recurs in the same spot periodically, especially during periods of stress. Rather than utilizing antifungal creams, angular herpes simplex is treated in the same way as a cold sore, with topical [[antiviral drug]]s such as [[aciclovir]].
===Irritation contact dermatitis===
[[File:Judaskopf (da Vinci).jpg|thumbnail|right|A famous sketch by [[Leonardo da Vinci]] in preparation to depict the face of [[Judas Iscariot]] in [[The Last Supper (Leonardo da Vinci)|The Last supper]]. The subject shows overclosure of the jaws and loss of facial support around the mouth.]]
[[File:Corner Lip Lift Before.JPG|thumb|right|Pronounced skin folds extending from the corner of the mouth.]]
{{Main|Irritant contact dermatitis}}
22% of cases of angular cheilitis are due to irritants.<ref name=Park2011P1 /> [[Saliva]] contains [[digestive enzyme]]s, which may have a degree of digestive action on tissues if they are left in contact.<ref name=Park2011P1 /> The corner of the mouth is normally exposed to saliva more than any other part of the lips. Reduced lower facial height (vertical dimension or facial support) is usually caused by [[edentulism]] (tooth loss), or wearing worn down, old dentures or ones which are not designed optimally. This results in overclosure of the mandible (collapse of the jaws),<ref name="Bruch 2010" /> which extenuates the angular
skin folds at the corners of the mouth,<ref name="Neville 2001" /> in effect creating an [[intertriginous]] skin crease. The tendency of saliva to pool in these areas is increased,<!-- <ref name="Neville 2001" /> --> constantly wetting the area,<ref name="Soames 1999" /> which may cause tissue maceration and favors the development of a yeast infection.<ref name="Neville 2001" /> As such, angular cheilitis is more commonly seen in edentulous people (people without any teeth).<ref name="Bruch 2010" /> It is by contrast uncommon in persons who retain their natural teeth.<ref name="Glick 2003" /> Angular cheilitis is also commonly seen in denture wearers.<ref name=schalock265>{{cite book|title=Primary Care Dermatology|publisher=Lippincott Williams & Wilkins, 2010|isbn=978-0-7817-9378-0|page=265|url=https://books.google.com/books?id=rtUWsKknDOoC&pg=PA53|editor=Peter C. Schalock, M.D.|editor2=Jeffrey T. S. Hsu, M.D.|editor3=Kenneth A. Arndt|url-status = live|archiveurl=https://web.archive.org/web/20170910173629/https://books.google.com/books?id=rtUWsKknDOoC&pg=PA53|archivedate=2017-09-10|df=|date=2010-09-15}}</ref> Angular cheilitis is present in about 30% of people with denture-related stomatitis.<ref name="Soames 1999">{{cite book|last=Soames JV, Southam JC|first=JV|title=Oral pathology|year=1999|publisher=Oxford Univ. Press|location=Oxford|isbn=978-0192628947|pages=197–98|edition=3rd}}</ref> It is thought that 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.<ref name=Park2011P1 /> Reduced vertical dimension can also be caused by tooth migration, wearing orthodontic appliances, and elastic tissue damage caused by [[ultraviolet light]] exposure and smoking.<ref name=Park2011P1 />
Habits or conditions that keep the corners of the mouth moist might include chronic lip licking, thumb sucking (or sucking on other objects such as pens, pipes, lollipops), dental cleaning (e.g. flossing), chewing gum, hypersalivation, drooling and [[mouth breathing]].<ref name=Park2011P1 /><ref name="Scully 2008" /><ref name="Neville 2001" /> Some consider habitual lip licking or picking to be a form of nervous [[tic]], and do not consider this to be true angular cheilitis,<ref name="Scully 2008" /> instead calling it ''perlèche'' (derived from the French word ''pourlècher'' meaning "to lick one’s lips"),<ref name=Park2011P1 /> or "[[Factitious disorder|factitious]] cheilitis" is applied to this habit.<ref name=Park2011P1 /> The term "cheilocandidiasis" describes exfoliative (flaking) lesions of the lips and the skin around the lips, and is caused by a superficial candidal infection due to chronic lip licking.<ref name="Neville 2001" /> Less severe cases occur during cold, dry weather, and is a form of [[chapped lips]]. Individuals may lick their lips in an attempt to provide a temporary moment of relief, only serving to worsen the condition.<ref>Gibson, Lawrence E., M.D., [http://www.mayoclinic.com/health/chapped-lips/AN01440 "Dry Skin"] {{webarchive|url=https://web.archive.org/web/20090915190506/http://mayoclinic.com/health/chapped-lips/an01440 |date=2009-09-15 }}, [[Mayo Clinic]]</ref>
The sunscreen in some types of lip balm degrades over time into an irritant. Using expired lipbalm can initiate mild angular cheilitis, and when the person applies more lipbalm to alleviate the cracking, it only aggravates it. Because of the delayed onset of contact dermatitis and the recovery period lasting days to weeks, people typically do not make the connection between the causative agent and the symptoms.{{medical citation needed|date=July 2013}}
===Nutritional deficiencies===
Several different [[Malnutrition|nutritional deficiency]] states of [[vitamin]]s or [[mineral]]s have been linked to AC.<ref name=Park2011P2 /> It is thought that in about 25% of people with AC, [[iron deficiency]] or deficiency of [[B vitamins]] are involved.<ref name=Park2011P2 /> Nutritional deficiencies may be a more common cause of AC in [[Third World]] countries.<ref name=Park2011P2 /> Chronic iron deficiency may also cause [[koilonychia]] (spoon shaped deformity of the fingernails) and [[glossitis]] (inflammation of the tongue). It is not completely understood how iron deficiency causes AC, but it is known that it causes a degree of [[Immunodeficiency|immunocompromise]] (decreased efficiency of the immune system) which may in turn allow an opportunistic infection of candida.<ref name=Park2011P2 /> [[Riboflavin#Deficiency|Vitamin B2 deficiency]] (ariboflavinosis) may also cause AC, and other conditions such as redness of [[mucous membrane]]s, magenta colored glossitis (pink inflammation of the tongue).<ref name=Park2011P2 /> [[Pantothenic acid|Vitamin B5]] deficiency may also cause AC, along with glossitis, and skin changes similar to [[seborrhoeic dermatitis]] around the eyes, nose and mouth.<ref name=Park2011P2 /> [[Vitamin B12 deficiency]] is sometimes responsible for AC, and commonly occurs together with [[folate deficiency]] (a lack of [[folate|folic acid]]), which also causes glossitis and [[megaloblastic anemia]].<ref name=Park2011P2 /> [[Vitamin B3 complex|Vitamin B3]] deficiency ([[pellagra]]) is another possible cause, and in which other association conditions such as [[dermatitis]], [[diarrhea]], [[dementia]] and glossitis can occur.<ref name=Park2011P2 /> [[Biotin]] (vitamin B7) deficiency has also been reported to cause AC, along with [[hair loss]] (alopecia) and [[xerophthalmia|dry eyes]].<ref name=Park2011P2 /> [[Zinc deficiency]] is known to cause AC.<ref name="Gaveau">{{cite journal |vauthors=Gaveau D, Piette F, Cortot A, Dumur V, Bergoend H |title=[Cutaneous manifestations of zinc deficiency in ethylic cirrhosis]. |journal=Ann Dermatol Venereol |volume=114 |issue=1 |pages=39–53 |year=1987 |pmid= 3579131}}</ref> Other symptoms may include diarrhea, [[alopecia]] and [[dermatitis]].<ref name=Park2011P2 /> [[Acrodermatitis enteropathica]] is an autosomal recessive genetic disorder causing impaired absorption of zinc, and is associated with AC.<ref name=Park2011P2 />
In general, these nutritional disorders may be caused by [[malnutrition]], such as may occur in [[alcoholism]] or in poorly considered diets, or by [[malabsorption]] secondary to gastrointestinal disorders (e.g. [[Coeliac disease]] or [[chronic pancreatitis]]) or gastrointestinal surgeries (e.g. [[Vitamin B12 deficiency anemia|pernicious anemia]] caused by [[ileum|ileal]] resection in [[Crohn's disease]]).<ref name=Park2011P2 />
===Systemic disorders===
Some systemic disorders are involved in angular cheilitis by virtue of their association with malabsorption and the creation of nutritional deficiencies described above. Such examples include people with [[anorexia nervosa]].<ref name=Park2011P2 /> Other disorders may cause lip enlargement (e.g. [[orofacial granulomatosis]]),<ref name=Park2011P2 /> which alters the local anatomy and extenuates the skin folds at the corners of the mouth. More still may be involved because they affect the immune system, allowing normally harmless organisms like Candida to become pathogenic and cause an infection. Xerostomia (dry mouth) is thought to account for about 5% of cases of AC.<ref name=Park2011P2 /> Xerostomia itself has many possible causes, but commonly the cause may be side effects of medications, or conditions such as [[Sjögren's syndrome]]. Conversely, conditions which cause [[drooling]] or [[sialorrhoea]] (excessive salivation) 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.<ref name=Park2011P2 /> This is due to relative [[macroglossia]], an apparently large tongue in a small mouth, which may constantly stick out of the mouth causing maceration of the corners of the mouth with saliva. [[Inflammatory bowel disease]]s (such as [[Crohn's disease]] or [[ulcerative colitis]]) can be associated with angular cheilitis.<ref name="Scully 2008" /> In Crohn's, it is likely the result of malabsorption and immunosuppressive therapy which gives rise to the sores at the corner of the mouth.<ref name="Bruch 2010" /> [[Glucagonoma]]s are rare [[pancreas|pancreatic]] [[endocrine tumor]]s which secrete [[glucagon]], and cause a syndrome of dermatitis, glucose intolerance, weight loss and anemia. AC is a common feature of glucagonoma syndrome.<ref name="Yamada 2009">{{cite book|editor=Tadataka Yamada|title=Textbook of gastroenterology|year=2009|publisher=Blackwell Pub.|location=Chichester, West Sussex|isbn=978-1-4051-6911-0|pages=1882–83|edition=5th|editor2=David Alpers |editor3=Anthony Kalloo |editor4=Neil Kaplowitz |editor5=Chung Owyang |editor6=Don Powell}}</ref> Infrequently, angular cheilitis may be one of the manifestations of [[chronic mucocutaneous candidiasis]],<ref name="Neville 2001">{{cite book|vauthors=Neville BW, Damm DD, Allen CA, Bouquot JE |title=Oral & maxillofacial pathology|year=2002|publisher=W.B. Saunders|location=Philadelphia|isbn=978-0721690032|pages=100, 192, 196, 266|edition=2nd}}</ref> and sometimes cases of oropharyngeal or esophageal candidiasis may accompany angular cheilitis.<ref name=Park2011P1 /> Angular cheilitis may be present in [[human immunodeficiency virus infection]],<ref name="Tyldesley 2003" /> [[neutropenia]],<ref name="Glick 2003" /> or [[diabetes]].<ref name="Scully 2008" /> Angular cheilitis is more common in people with [[eczema]] because their skin is more sensitive to irritants.<ref name=Park2011P1 /> Other conditions possibly associated include [[plasma cell gingivitis]],<ref name="Wood 1997" /> [[Melkersson-Rosenthal syndrome]],<ref name=Park2011P2 /> or [[sideropenic dysphagia]] (also called Plummer-Vinson syndrome or Paterson-Brown-Kelly syndrome).<ref name=Park2011P2 />
===Drugs===
Several drugs may cause AC as a side effect, by various mechanisms, such as creating drug-induced xerostomia. Various examples include [[isotretinoin]],<!-- <ref name=Park2011P2 /> --> [[indinavir]],<!-- <ref name=Park2011P2 /> --> and [[sorafenib]].<ref name=Park2011P2 /> Isotretinoin (Accutane), an analog of [[vitamin A]], is a medication which dries the skin. Less commonly, angular cheilitis is associated with primary [[hypervitaminosis A]],<ref>Kliegman: Nelson Textbook of Pediatrics, 18th ed.</ref> which can occur when large amounts of liver (including cod liver oil and other fish oils) are regularly consumed or as a result from an excess intake of vitamin A in the form of vitamin supplements. Recreational drug users may develop AC. Examples include [[cocaine]],<!-- <ref name=Park2011P2 /> --> [[methamphetamine]]s,<!-- <ref name=Park2011P2 /> --> [[heroin]],<!-- <ref name=Park2011P2 /> --> and [[hallucinogen]]s.<ref name=Park2011P2 />
===Allergic contact dermatitis===
{{see also|Allergic contact cheilitis|Allergic contact dermatitis|Allergic contact stomatitis}}
[[File:Epikutanni-test.jpg|thumb|[[Patch test]]]]
Allergic reactions may account for about 25–34% of cases of generalized cheilitis (i.e., inflammation not confined to the angles of the mouth). It is unknown how frequently allergic reactions are responsible for cases of angular cheilitis, but any substance capable of causing generalized allergic cheilitis may present involving the corners of the mouth alone.
Examples of potential [[allergen]]s include substances that may be present in some types of lipstick, toothpaste, acne products, cosmetics, chewing gum, mouthwash, foods, dental appliances, and materials from dentures or mercury containing amalgam fillings.<ref name=Park2011P1 /> It is usually 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 ill fitting dentures may cause wrinkling at the corners of the lip that creates a favorable environment for the condition.<ref>{{cite journal |last1=Devani |first1=Alim |last2=Barankin |first2=Benjamin |title=Answer: Can you identify this condition? |journal=Canadian Family Physician |date=2007 |volume=53 |issue=6 |pages=1022–1023 |issn=0008-350X|pmc=1949217}}</ref> This can be corrected with onlays or crowns on the worn teeth to restore height or new dentures with "taller" teeth. The loss of vertical dimension has been associated with angular cheilitis in older individuals with an increase in facial laxity.<ref>{{cite web |title=How Do I Manage a Patient with Angular Cheilitis? {{!}} jcda |url=http://www.jcda.ca/article/d68 |website=www.jcda.ca |accessdate=8 June 2018 |language=en}}</ref>
==Diagnosis==
[[File:Photographic Comparison of a Canker Sore, Herpes, Angular Cheilitis and Chapped Lips..jpg|thumb|Photographic Comparison of: 1) a [[Canker Sore]] - inside the mouth, 2) [[Herpes]], 3) Angular Cheilitis and 4) [[Cheilitis#Chapped lips|Chapped Lips]].]]
Angular cheilitis is normally a diagnosis made clinically. If the sore is unilateral, rather than bilateral, this suggests a local factor (''e.g.'', trauma) or a split [[syphilitic]] [[papule]].<ref name="Scully 2008" /><ref name="Leyse-Wallace2013">{{cite book|last=Leyse-Wallace|first=Ruth|title=Nutrition and Mental Health|url=https://books.google.com/books?id=B9KrxydnZ_cC&pg=PA246|accessdate=17 September 2014|date=29 January 2013|publisher=CRC Press|isbn=9781439863350|page=246|url-status = live|archiveurl=https://web.archive.org/web/20170910173629/https://books.google.com/books?id=B9KrxydnZ_cC&pg=PA246|archivedate=10 September 2017|df=}}</ref> Angular cheilitis caused by [[mandibular]] overclosure, drooling, and other irritants is usually bilateral.<ref name=Park2011P1 />
The lesions are normally swabbed to detect if [[Candida (fungus)|Candida]] or [[pathogenic]] [[bacterial]] [[species]] may be present. Persons with angular cheilitis who wear dentures often also will have their denture swabbed in addition. A [[complete blood count]] (full blood count) may be indicated, including assessment of the levels of [[iron]], [[ferritin]], [[vitamin B12]] (and possibly other [[B vitamins]]), and [[folate]].<ref name="Scully 2008" />
===Classification===
Angular cheilitis could be considered to be a type of cheilitis or [[stomatitis]]. Where Candida species are involved, angular cheilitis is classed as a type of [[oral candidiasis]], specifically a primary (group I) Candida-associated lesion.<ref name="Tyldesley 2003">{{cite book|vauthors=Tyldesley WR, Field A, Longman L |title=Tyldesley's Oral medicine|year=2003|publisher=Oxford University Press|location=Oxford|isbn=978-0192631473|pages=37, 40, 46, 63–67|edition=5th}}</ref> This form angular cheilitis which is caused by Candida is sometimes termed "Candida-associated angular cheilitis",<ref name="Tyldesley 2003" /> or less commonly, "monilial perlèche".<ref name=Park2011P1 /> Angular cheilitis can also be classified as acute (sudden, short-lived appearance of the condition) or chronic (lasts a long time or keeps returning), or [[refractory disease|refractory]] (the condition persists despite attempts to treat it).<ref name=Park2011P1/>
== Management==
There are 4 aspects to the treatment of angular cheilitis.<ref name="Samaranayake 2009">{{cite book|last=Samaranayake|first=LP|title=Essential microbiology for dentistry|year=2009|publisher=Elseveier|isbn=978-0702041679|pages=296–97|edition=3rd}}</ref> Firstly, potential reservoirs of infection inside the mouth are identified and treated.<ref name="Samaranayake 2009" /> [[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.<ref name="Coulthard 2008" /><ref name=schalock265/> This involves having dentures properly fitted and disinfected. Commercial preparations are marketed for this purpose, although dentures may be left in dilute (1:10 concentration) household [[bleach]] overnight, but only if they are entirely plastic and do not contain any metal parts, and with rinsing under clean water before use.<ref name="Bruch 2010" /> Improved denture hygiene is often required thereafter, including not wearing the denture during sleep and cleaning it daily.<ref name="Scully 2008" /> For more information, see [[Denture-related stomatitis#Treatment|Denture-related stomatitis]].
Secondly, there may be a need to increase the vertical dimension of the lower face to prevent overclosure of the mouth and formation of deep skin folds.<ref name="Samaranayake 2009" /> This may require the construction of a new denture with an adjusted bite.<ref name="Scully 2008" /> Rarely, in cases resistant to normal treatments, surgical procedures such as [[Collagen injection#Cosmetic surgery|collagen injections]] (or other facial fillers such as autologous fat or crosslinked [[hyaluronic acid]]) are used in an attempt to restore the normal facial contour.<ref name=Park2011P1 /><ref name="Scully 2008" /> Other measures which seek to reverse the local factors that may be contributing to the condition include improving [[oral hygiene]], stopping smoking or other tobacco habits and use of a barrier cream (e.g. [[zinc oxide]] paste) at night.<ref name=Park2011P1 />
Thirdly, treatment of the infection and inflammation of the lesions themselves is addressed. This is usually with [[Topical medication|topical]] [[antifungal medication]],<ref name="Coulthard 2008" /> such as [[clotrimazole]],<ref name="Neville 2001" /> [[amphotericin B]],<ref name="Samaranayake 2009" /> [[ketoconazole]],<ref name="Glick 2003" /> or [[nystatin]] cream.<ref name="Bruch 2010" /> Some antifungal creams are combined with [[corticosteroid]]s such as [[hydrocortisone]]<ref name="Coulthard 2008" /> or [[triamcinolone]]<ref name="Bruch 2010">{{cite book|vauthors=Treister NS, Bruch JM |title=Clinical oral medicine and pathology|year=2010|publisher=Humana Press|location=New York|isbn=978-1-60327-519-4|pages=92–93, 144}}</ref> to reduce inflammation, and certain antifungals such as [[miconazole]] also have some [[antibacterial]] action.<ref name="Coulthard 2008" /> [[Diiodohydroxyquinoline]] is another topical therapy for angular cheilitis.<ref name="Neville 2001" /> If ''Staphylococcus aureus'' infection is demonstrated by microbiological culture to be responsible (or suspected), the treatment may be changed to [[fusidic acid]] cream,<ref name="Coulthard 2008" /> an antibiotic which is effective against this type of bacteria. Aside from fusidic acid, [[neomycin]],<ref name="Samaranayake 2009" /> [[mupirocin]],<ref name=Park2011P1 /> [[metronidazole]],<ref name="Wood 1997" /> and [[chlorhexidine]]<ref name="Samaranayake 2009" /> are alternative options in this scenario.
Finally, if the condition appears resistant to treatment, investigations for underlying causes such as anemia or nutrient deficiencies or HIV infection.<ref name="Samaranayake 2009" /> Identification of the underlying cause is essential for treating chronic cases. The lesions may resolve when the underlying disease is treated, e.g. with a course of oral iron or B vitamin supplements.<ref name="Scully 2008" /> [[Patch test]]ing is recommended by some in cases which are resistant to treatment and where allergic contact dermatitis is suspected.<ref name=Park2011P1 />
==Prognosis==
Most cases of angular cheilitis respond quickly when antifungal treatment is used.<ref name="Glick 2003">{{cite book|vauthors=Greenberg MS, Glick M |title=Burket's oral medicine diagnosis & treatment|year=2003|publisher=BC Decker|location=Hamilton, Ont.|isbn=978-1550091861|pages=97–98, 550|edition=10th}}</ref> In more long standing cases, the severity of the condition often follows a relapsing and remitting course over time.<ref name="Neville 2001" /> The condition can be difficult to treat and can be prolonged.<ref name="Scully 2008" />
==Epidemiology==
AC is a relatively common condition,<ref name="Tyldesley 2003" /> accounting for between 0.7 – 3.8% of oral mucosal lesions in adults and between 0.2 – 15.1% in children, though overall it occurs most commonly in adults in the third to sixth decades of life.<ref name=Park2011P1 /><ref name="Scully 2008"/> It occurs worldwide, and both males and females are affected.<ref name="Scully 2008" /> Angular cheilitis is the most common presentation of fungal and bacterial infections of the lips.<ref name="Neville 2001" />
==Etymology==
The term "angular cheilitis" is from [[Ancient greek]], ''χείλος'' meaning lip and -itis meaning inflammation.
== References ==
{{Reflist}}
== External links ==
{{Medical resources
| DiseasesDB = <!-- none -->
| ICD10 = {{ICD10|K|13|0|k|00}}
| ICD9 = {{ICD9|528.5}}, {{ICD9|686.8}}
| ICDO =
| OMIM =
| MedlinePlus = <!-- none -->
| eMedicineSubj = <!-- none -->
| eMedicineTopic =
| MeshID = D002613
}}
{{Commons category|Angular cheilitis}}
{{Oral pathology}}
[[Category:Lip disorders]]
[[Category:Conditions of the mucous membranes]]
[[Category:Mycosis-related cutaneous conditions]]
[[Category:RTT]]
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