10 angular stomatitis facts

10 angular stomatitis facts

In this article we will describe 10 facts about angular stomatitis, focusing on its causes, investigation and treatment.

1. Definition

Types

• Infectious angular stomatitis: Caused by fungal, viral or bacterial infection
• Nutritional angular stomatitis: Related to deficiencies in vitamins (e.g. B12) or minerals (e.g. iron)
• Irritant angular stomatitis: Caused by local irritation (e.g. mouthwash, food).

2. Epidemiology

• Older adults
• Individuals with dentures or other oral prosthetics
• Those with nutritional deficiencies or systemic disease (e.g. diabetes, anaemia).

3. Risk Factors

• Poor oral hygiene
• Malnutrition
• Dry mouth (xerostomia)
• Smoking
• Certain medications (e.g. isotretinoin, phenytoin).

4. Causes

• Fungal or bacterial:

  • Candida species alone (usually Candida albicans), which accounts for about 20% of cases
  • Bacterial species, either:
    • Staphylococcus aureus alone, which accounts for about 20% of cases
    • β-haemolytic streptococci alone. These types of bacteria have been detected in between 10–15% of cases, but less commonly are they present in isolation
    • Or a combination of the above organisms, (a polymicrobial infection) with about 60% of cases involving both C. albicans and S. aureus.
  • Candida can be detected in about 90% of angular stomatitis lesions. But this organism is found in the mouths of about 40% of healthy individuals, and it is considered to be normal commensal component of the oral microbiota
  • Note. Angular stomatitis is not contagious like cold sores.
• Local irritation
• Antiretroviral treatment
• Vitamin deficiency including vitamin B2/6/12, or mineral deficiency (iron or zinc)
• A compromised immune system (e.g. if a person’s immune system is not working effectively because of diabetes or drugs used in immuno/chemotherapy to treat autoimmne disease or cancer)
• Genetic – e.g. in Down syndrome.

5. Symptoms and Signs

• Redness and inflammation at the corners of the mouth
• Cracking or fissuring of the skin
• Pain or tenderness
• Swelling
• Difficulty eating or speaking.

6. Diagnosis

• Medical history
• Physical examination
• Laboratory tests (e.g. fungal or bacterial cultures) may be necessary to identify underlying infections.

7. Investigation

Most people do not need investigation.

• But if first-line antifungal/antibiotic combination yields no improvement in 2 to 3 weeks, testing should include:
  • FBC, including Hb (with MCV)
  • Ferritin (iron level), zinc
  • Vitamin B2/B3/B5/B6/B12
  • HbA1c and fasting blood glucose
• Oral swabs or biopsies to diagnose fungal or bacterial infections
• Imaging studies (e.g. x-rays) to evaluate dental or facial anatomy.

Note. If anaemia is discovered it should be investigated properly. If iron deficiency is diagnosed, you should investigate for chronic bleeding.

Differential Diagnosis

• Cold sores (herpes simplex)
• Impetigo
• Eczema
• Vitiligo
• Secondary syphilis/syphilitic papule (more likely unilateral)
• Oral lichen planus.

8. Treatment

In many cases, no treatment is needed and angular stomatitis resolves by itself.

General measures

• Use of lip balm or a thick emollient ointment applied frequently (often sufficient treatment alone for saliva-induced angular stomatitis)
• Topical antiseptics.

Specific measures

• Topical antifungal cream
• Oral antifungal medication
• Topical or oral antistaphylococcal antibiotic
• Topical steroid ointment if the skin is significantly inflamed
• Nutritional supplements
• Moisturisers or emollients
• Dental treatment (e.g. adjusting dentures).

Ok, but what should you actually do?

• If it doesn’t resolve by itself in 3-4 days with lip balm etc, a good first treatment is miconazole-hydrocortisone cream for 7 days – this combination will reduce inflammation and treat candida infection
• Also many gram positive bacteria including streptococci and staphylococci are sensitive to miconazole.

When to See a Doctor or Dentist 

9. Complications

• Chronic inflammation
• Scarring
• Infection spread to other areas of the mouth or face
• Nutritional deficiencies or systemic diseases (if left unaddressed).

10. Prognosis

• In many cases angular stomatitis gets better of its own accord. If not it is usually curable and rarely results in permanent scarring or pigmentation
• Improvement is usually seen within the first few days of treatment and typically resolves by two weeks
• However, recurrence is possible if underlying causes are not addressed.

Summary

We have described 10 facts about angular stomatitis, focusing on its causes, investigation and treatment. We hope it has been helpful.