Approach
Treatment is often challenging and may be lengthy. Successful therapy is based on identifying and correcting each and all factors of this multi-factorial condition. Treatment should be based on the suspected cause rather than used in an algorithmic manner. For all patients, nutritional deficiency identification and treatment is optimal.[2]
Infectious aetiology
First-line therapies include topical miconazole after meals and at bedtime to treat Candida albicans.[2] Miconazole may be used to treat mixed fungal and bacterial infections, as it has gram-positive bacteriostatic action as well. Oral fluconazole is a useful second-line alternative. Miconazole is absorbed systemically and may potentiate the action of warfarin, phenytoin, and sulfonylureas; thus, topical nystatin or amphotericin-B are first-line therapies in patients taking these drugs.[13][23][24] However, topical amphotericin-B products are not currently available in some countries.
Chronic corticosteroid inhaler therapy may also predispose the patient to Candida albicans infection, due to immune suppression. Rinsing of the mouth after inhaler treatment will help eliminate intraoral accumulation of corticosteroid.[25]
Topical mupirocin or a polymyxin-containing preparation are valuable in treating staphylococcal colonisation.[2][13][24] In the case of staphylococcal colonisation of the nares, this should also be eradicated.
Patients whose angular cheilitis resists treatment require systemic antifungal therapy (e.g., fluconazole) and amphotericin-B lozenges, if available.[26] Second-line therapy includes the use of dermal fillers in the commissures.[27][28] Prosthodontic evaluation and construction is an option for older patients who suffer from chronic drooling and angular cheilitis.[29] Also described is a method to incorporate a cannula into the denture prosthesis to channel the saliva towards the oropharyngeal area for older and disabled patients.[29]
Non-infectious aetiology
For all patients, nutritional deficiencies should be identified and corrected.[2]
Depending on patch test results, avoidance of the specific identified allergen is recommended.
Identification of chronic reservoirs of infection, such as dentures, is vital. Dentures are recommended to be removed at night and cleansed well before re-insertion in the morning. At night, the dentures may be stored in hypochlorite or chlorhexidine.
Recommendation is to reduce mechanical stress, including a dental referral for identification and correction of poorly fitting dentures. New dentures may restore facial contours, increasing the vertical dimension of the jaws and face.[22]
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