Dermatology & Oral Medicine
Angular cheilitis Perleche
Angular cheilitis, commonly referred to as perleche, is an acute or chronic inflammation of the labial commissures—the corners of the mouth where the upper and lower lips meet—manifesting as painful fissures, erythema, skin maceration, and sometimes crusting or scaling at the corners of the mouth. While it may seem harmless at first glance, perleche often reflects one or more underlying conditions that should be identified and treated to prevent recurrence: a fungal infection Candida albicans (the most common), a bacterial infection Staphylococcus aureus or streptococcal disease, nutritional deficiencies (iron, zinc, vitamins B2 and B12), unbalanced or poorly balanced diabetes mellitus, immunosuppression, or local anatomical factors favoring maceration (deep commissural folds in edentulous patients or those with ill-fitting dentures, loss of vertical dimension of the occlusion). Perlachia affects all age groups - infants (excessive salivation, prolonged thumb or pacifier sucking), edentulous elderly people or those with removable dentures, and adults with systemic predisposing factors - but its prevalence is particularly high in immunocompromised patients (HIV, chemotherapy, prolonged corticosteroid therapy) and those with Sjögren's syndrome or chronic xerostomia. The course is usually favorable with treatment targeted at the etiological agent, but chronic recurrent forms require further investigation to identify and correct underlying systemic contributing factors. If a commissural lesion is persistent, indurated, unilateral or unresponsive to standard treatment, a biopsy is imperative to rule out squamous cell carcinoma of the labial commissure.
Causes and etiological factors
Angular cheilitis is most often multifactorial, with a primary cause frequently amplified by local or systemic predisposing factors:
| Etiology | Frequency / Context | Key features |
|---|---|---|
| Infection Candida albicans | Most frequent cause (50–70% of cases) | Saprophytic yeast from the oral cavity that proliferates in macerated conditions; shiny erythematous appearance, oozing, with possible whitish coating; often associated with oral candidiasis (thrush) or removable dentures (prosthetic stomatitis); predisposing factors: diabetes, recent antibiotics, corticosteroid therapy, immunosuppression, xerostomia, ill-fitting dentures; topical antifungal treatment (miconazole, nystatin) ± systemic treatment depending on severity. |
| Bacterial infectionStaphylococcus aureus, streptococci) | Frequent, often associated with Candida (co-infection) | Staphylococcus aureus predominant in pure bacterial forms; crusty, yellowish appearance (impetiginized); possible serous discharge and crusts; candidal and bacterial co-infection is frequent, justifying the use of combined antifungal-antibacterial treatment (miconazole, which also has antibacterial activity against S. aureus) ; treatment: topical fusidic acid or mupirocin if bacterial; miconazole cream if co-infection |
| Iron deficiency (iron deficiency anemia) | Frequent systemic cause to look for | Iron deficiency compromises the integrity of the mucosal epithelium and reduces local immune defenses; angular cheilitis, often bilateral and recurrent; associated signs: glossitis (red, smooth, painful tongue - Hunter's glossitis), koilonychia (spoon nails), asthenia, pale conjunctivae; iron studies are essential (ferritin, serum iron, transferrin saturation) for any recurrent angular cheilitis; oral iron supplementation after correcting the cause of the deficiency. |
| Vitamin B deficiencies (B2 - riboflavin, B12) | Nutritional cause to consider | Riboflavin (B2) is essential for mucosal integrity; its deficiency (ariboflavinosis) causes angular cheilitis, glossitis, and seborrheic facial dermatitis; B12 deficiency (vegans, atrophic gastritis, pernicious anemia) can also manifest as angular cheilitis in the context of megaloblastic anemia; measure vitamins B12 and folate if the context is suggestive. |
| Zinc deficiency | Nutritional deficiency or malabsorption | Zinc is essential for epithelial healing and skin immunity; deficiency is common in the elderly, vegans, chronic alcoholics, patients with inflammatory bowel disease (Crohn's, ulcerative colitis), or those with digestive fistulas; angular cheilitis in the context of enteropathic acrodermatitis (periorificial, perineal, and acral lesions). |
| Diabetes mellitus | Major systemic predisposing factor | Chronic hyperglycemia promotes the proliferation of Candida (high salivary glucose) alters cellular immunity and reduces healing; any recurrent angular cheilitis without another obvious cause should prompt investigation for undiagnosed diabetes (fasting blood glucose, HbA1c); glycemic control directly influences treatment response and the risk of recurrence. |
| Local anatomical factors and vertical dimension loss | Common in edentulous elderly people | Loss of vertical dimension of occlusion due to edentulism or ill-fitting dentures - accentuation of commissural folds with saliva accumulation in the corners of the mouth (chronic maceration); denture stomatitis under a removable prosthesis; dental or prosthetic treatment essential to correct the contributing mechanical factor |
| Contact dermatitis, perioral eczema | Non-infectious cause to eliminate | Allergic or irritant reaction to cosmetic products (lipstick, lip balm, toothpaste), foods (citrus, tomatoes), orthodontics (nickel), or habits (lip licking, lip biting); non-infectious appearance, without whitish coating or meliceric crusts; treatment: allergen avoidance, emollient, low-potency topical corticosteroid; patch test if contact allergy is suspected |
Risk factors
- Immunosuppression: HIV/AIDS (frequent and recurrent oropharyngeal candidiasis in the context of profound immunosuppression with CD4 < 200/mm³), cytotoxic chemotherapy, prolonged systemic corticosteroid therapy, immunosuppressants (transplantation, autoimmune diseases) - often severe, resistant, and recurrent forms requiring systemic antifungal treatment
- Recent broad-spectrum antibiotic therapy: destruction of the commensal oropharyngeal bacterial flora with secondary proliferation of Candida ; Perleche classically appearing in 1 to 3 weeks following prolonged antibiotic treatment
- Xerostomia (dry mouth): reduced salivary flow due to Sjögren's syndrome, medications (anticholinergics, antihistamines, tricyclic antidepressants, diuretics, antihypertensives), cervicofacial radiotherapy, dehydration—saliva is normally protective due to its antifungal properties (lactoferrin, lysozyme, secretory IgA), its reduction favors colonization by Candida
- Oral habits promoting maceration: chronic lip and commissure licking (lip-licking cheilitis), thumb or pacifier sucking in infants, wearing orthodontic appliances, hypersalivation (nocturnal drooling, antipsychotic treatment)
- Restrictive diet, malnutrition, malabsorption: strict veganism without adequate supplementation, anorexia nervosa, celiac disease, inflammatory bowel disease (Crohn's, ulcerative colitis), bariatric surgery — risk of multiple deficiencies in iron, zinc, and B vitamins
- Advanced age and edentulism: accumulation of predisposing factors (immunosenescence, loss of vertical dimension, ill-fitting prosthesis, medication-induced xerostomia, relative malnutrition)
Symptoms
- Painful fissures or cracks at the corners of the lips: cardinal symptom; pain when opening the mouth (eating, brushing teeth, speaking); the fissures may bleed when the mouth is opened wide and become secondarily infected
- Erythema and maceration of the corners of the mouth: redness, moisture, and softening of the skin at the corners; shiny and slightly weeping appearance characteristic of the candidal form; yellowish or meliceric crusts if there is a secondary bacterial infection.
- Whitish coating at the corners: detachable whitish deposit suggestive of an infection Candida ; can spread to the adjacent oral mucosa (associated oral thrush)
- Bilateral involvement in the vast majority of cases: bilaterality is the rule in perlèche of systemic origin (deficiency, diabetes, immunodeficiency); persistent or asymmetric unilateral involvement should suggest a differential diagnosis (squamous cell carcinoma, localized impetigo).
- Itching and local burning sensation: particularly pronounced in candidiasis and contact dermatitis.
- Associated signs pointing to the cause: glossitis (B2, B12, iron deficiency), pale mucous membranes (iron deficiency anemia), recurrent canker sores (celiac disease, Crohn's disease), visible oral candidiasis (thrush - white plaques that can be scraped off the oral mucosa) in the context of immunosuppression
ℹ️
Recurrent angular cheilitis or angular cheilitis resistant to first-line antifungal treatment should not be considered trivial. It necessitates a systematic search for underlying causes: a complete iron panel (ferritin, serum iron), fasting blood glucose and HbA1c (diabetes), vitamin B12 and folate levels, a nutritional assessment with zinc and riboflavin levels if the context is suggestive, and screening for immunodeficiency if indicated. Treating only the commissural lesion without correcting the systemic predisposing factor inevitably leads to recurrence.
Diagnosis
- Local clinical examination: appearance of the corners of the mouth (bilaterality, fissures, erythema, maceration, whitish coating, crusts), extension to the oral mucosa, state of dentures and occlusion, general oral hygiene; search for associated oral candidiasis (thrush, denture stomatitis)
- Local mycological sample: swab of the commissures for fungal culture (species identification Candida and an antifungal susceptibility test) — indicated in case of resistance to first-line treatment or severe form; bacterial culture if impetiginized appearance
- Biological assessment oriented according to clinical context: ferritin, serum iron, transferrin saturation (iron deficiency); CBC-platelets (iron deficiency or megaloblastic anemia); fasting blood glucose and HbA1c (diabetes); vitamin B12, folate (vitamin deficiency); plasma zinc; TSH if context of unexplained xerostomia; HIV serology if risk factors or unexplained immunosuppression
- Dental and prosthodontic evaluation: assessment of vertical dimension of occlusion, condition and fit of removable dentures, and prosthetic hygiene—essential in edentulous elderly patients or those wearing dentures.
- Commissural biopsy: imperatively indicated for any persistent (> 4–6 weeks) or unresponsive unilateral commissural lesion, or a lesion that is indurated or vegetative — to rule out squamous cell carcinoma of the labial commissure
- Allergy patch testing: if contact dermatitis is suspected (atopic history, occupational exposure, cosmetics) — identification of the responsible allergen
Treatment
- Topical antifungal (first-line treatment): miconazole cream 2% % — treatment of choice because it is active against Candida and on Staphylococcus aureus (Double antifungal and antibacterial activity); apply twice daily to the corners of the mouth for 2 to 4 weeks; nystatin cream if miconazole is unavailable; clotrimazole cream as an alternative
- Systemic antifungal: fluconazole 150 mg as a single dose or 50–100 mg/day for 7–14 days — indicated for severe forms, extensive associated oral candidiasis, resistance to topical treatment, or significant immunosuppression; itraconazole for species of Candida fluconazole-resistantC. glabrata, C. krusei)
- Antibiotique topique si composante bactérienne prédominante : acide fusidique crème 2 % ou mupirocine crème 2 % — 2 à 3 fois par jour pendant 7–10 jours en cas d'impétiginisation ou de S. aureus to the culture
- Low-potency topical corticosteroid: hydrocortisone 1 % or desonide — short-term (5-7 days) combination with antifungal to reduce inflammation and pain, never as monotherapy (risk of worsening fungal infection); contraindicated if infection is uncontrolled
- Emollient and lipid barrier: petrolatum or unscented lip balm, lanolin — protective post-treatment application to maintain hydration and reduce maceration from moisture; particularly useful in hypersalivating patients or those with lip-licking tics
- Correction of nutritional deficiencies: oral iron supplementation (ferrous sulfate or gluconate) after biological confirmation of deficiency; vitamin B12 via monthly IM injections or daily oral administration depending on the cause; zinc gluconate or zinc sulfate if deficiency is confirmed; folic acid if folate deficiency
- Dental and Prosthetic Treatment: Adjustment or Replacement of ill-fitting Removable Dentures, Treatment of Denture Stomatitis with Antifungal and Denture Disinfection (soaking in an antifungal solution - nystatin or chlorhexidine), Restoration of Vertical Occlusal Dimension
- Xerostomia treatment: saliva stimulation with artificial saliva (spray), oral pilocarpine if indicated, adequate hydration, review of xerostomia-inducing medications if possible
- Relapse prevention: Treatment of underlying systemic factors (glycemic balance, correction of deficiencies, treatment of immunosuppression if possible), rigorous oral hygiene, cessation of lip licking and prolonged pacifier use, regular application of lip balm.
Signs requiring immediate medical evaluation
Any unilateral commissural lesion that persists for more than 4 to 6 weeks despite appropriate antifungal treatment, presents with a hardened, warty, or ulcerated appearance, or is accompanied by cervical lymphadenopathy, should undergo urgent biopsy to rule out squamous cell carcinoma of the labial commissure. Similarly, oral candidiasis in an adult without an obvious predisposing factor (no recent antibiotics, no corticosteroids) should lead to screening for HIV and underlying immunodeficiency.
For a medical evaluation of recurrent or treatment-resistant perlèche, a nutritional assessment, or diabetes screening, Clinique Omicron offers consultations at our Quebec locations as well as via telemedicine. To book an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron physicians evaluate recurrent or resistant angular cheilitis, prescribe appropriate biological testing (iron studies, blood glucose, vitamin B12, zinc), refer to a dentist or dermatologist as appropriate, and initiate correction of identified systemic contributing factors. Consultations are available at our Quebec branches and via telemedicine throughout the province. To book an appointment, visit cliniqueomicron.ca.
The content of this page is for informational purposes only and does not substitute for the advice of a qualified healthcare professional. A persistent, indurated, or atypical commissural lesion requires medical evaluation and biopsy if indicated to rule out malignancy.
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