History and exam

Key diagnostic factors

common

dentures with palatal erythema

Suggests denture stomatitis and possible candidiasis.[2][13]

oral candidiasis

Suggests Candida albicans as the etiology.[2]

Other diagnostic factors

common

pruritus

If severe, indicates allergic contact dermatitis.

painful red fissures

Appear at corner of mouth as a single fissure, a single deeper and longer fissure following a skin fold, several fissures radiating from the corners of the mouth, or erythema of the skin adjacent to the corners of the mouth without fissures.

eczematous dermatitis of lower face

Suggests a staphylococcal infection as the etiology.

May also be medication reaction.

uncommon

specific medications

Some medications may induce xerostomia or angular cheilitis.

Sorafenib (multikinase inhibitor) has been reported to produce angular cheilitis.[6]

history of inflammatory bowel disease

GI symptoms may occur, such as diarrhea, constipation, or bloody stool.

history of acid reflux

There may be a history of acid reflux.

history of total parenteral nutrition

May be associated with malnutrition.

history of eating disorders

With dental caries, an eating disorder is a possible etiology.

alopecia

Fissures with alopecia, diarrhea, and oral ulcerations suggest a zinc deficiency.[2]

diarrhea/constipation

May occur secondary to inflammatory bowel disease or zinc deficiency.[2]

Fissures with alopecia, diarrhea, and oral ulcerations suggest a zinc deficiency.

bloody stool

May occur secondary to inflammatory bowel disease.

aphthous ulcers

Indicates iron deficiency with or without anemia.

Fissures with alopecia, diarrhea, and oral ulcerations suggest a zinc deficiency.

pale, depapillated atrophic tongue

Suggestive of iron deficiency.[2]

red, glossy, depapillated tongue

Suggestive of folate or niacin deficiency.[2]

red atrophic tongue

Suggestive of vitamin B12 deficiency.[2]

reddish-purple depapillated tongue

Suggestive of riboflavin deficiency.[2]

smooth, shiny red lips

Suggestive of riboflavin deficiency.[2]

dental caries

With dental caries, an eating disorder is a possible etiology.

palatal erosions

Abnormal mucosal changes such as palatal erosions may be seen on exam.

Risk factors

strong

age >75 years

More common in older people.[5]

male sex

There is a two-fold increase in men.[5]

dentures

The odds increase three-fold in denture users.[5]

Poor denture hygiene may cause mucosal injury or infection via dentures.

immune deficiency

Frequently present in patients with HIV; 10% may have localized candidiasis.[8]

Immunosuppressive medication (e.g., chemotherapy) also increases risk.

Down syndrome

Seen in 25% of patients with trisomy 21.[15]

xerostomia

Either as isolated xerostomia or as part of Sjogren syndrome.[11]

chronic inflammatory skin disease

Atopic dermatitis, perioral dermatitis, and allergic contact dermatitis at the commissures can cause angular cheilitis.[13][18]

An eczematous dermatitis may appear on the cheek or chin, as in infective eczematoid reaction, or as a reaction to topical medications.

diabetes mellitus

More common in people with insulin-dependent diabetes.[19]

In people with diabetes, angular cheilitis is more commonly associated with Candida albicans.[19]

weak

Crohn disease

Crohn disease or orofacial granulomatosis may be found in a very small minority of patients with angular cheilitis.[9][13]

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