Etiology
The condition is multifactorial in origin and can be broadly grouped according to one, or a combination of several different factors. Unilateral lesions are usually induced by trauma and are short-lived, whereas bilateral lesions often represent an infectious cause or underlying disease process.[3]
Infective agents: Candida albicans and Staphylococcus aureus are often isolated alone or in combination.[3][10][11]C albicans is often isolated in patients wearing dentures, or in people with diabetes. Angular cheilitis associated with candidiasis may be a manifestation of an underlying immunologic deficiency such as HIV, diabetes mellitus, or chronic granulomatous disease. In outbreaks of acute pustular and fissured cheilitis occurring in children, staphylococci and streptococci have been isolated.[12]
Mechanical factors: maceration of the commissural epithelium is often the primary cause of noninfectious cheilitis, brought on by dental trauma, flossing, excessive salivation, drooling, habitual licking, and ill-fitting dentures.[2][11][13] The aging process leads to resultant anatomic changes, including loss of vertical dimension between mandible and maxilla and overhanging skin folds. These changes can lead to angular cheilitis.[14] In Down syndrome, prognathism (jaw protrusion) and hypersalivation may lead to cheilitis.[15] Xerostomia (dry mouth), isolated or as part of Sjogren syndrome, can lead to cheilitis as well.[11] In children, lip-licking and thumb-sucking behavior can also be causative.
Nutritional deficiencies: deficiencies of riboflavin, niacin, folate, iron, vitamin B12, and zinc, and general protein malnutrition, show evidence of causation.[2][11] Angular cheilitis may be the manifestation of any systemic disorder that predisposes a patient to malnutrition, such as inflammatory bowel disease, eating disorders, or a history of total parenteral nutrition.[16][17]
Drug-related side effects: some medications can lead to angular cheilitis. It is a common side effect of treatment with isotretinoin, and the antiretroviral medication indinavir.[6] Sorafenib (multikinase inhibitor) has been reported to produce angular cheilitis.[6]
Pathophysiology
Maceration due to various etiologic factors leads to a disrupted epidermal barrier and provides an ideal environment for fungal and bacterial organisms.[2] Edentulous patients experience bone resorption of the mandible, and this also results in sagging of the facial tissue and excessive folds at the commissures. Saliva accumulation and moisture trapping provide an ideal environment for secondary opportunistic infection.
Classification
Clinical classification[3]
A single rhagad (painful fissure)
A single deeper and longer rhagad following a skin fold
Several rhagades radiating from the corners of the mouth
Erythema of the skin adjacent to the corners of the mouth without rhagades.
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