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Angular Cheilitis, Part 1: Local Etiologies

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Angular Cheilitis, Part 1: Local Etiologies Angular Cheilitis, Part 1: Local Etiologies Kelly K. Park, MD; Robert T. Brodell, MD; Stephen E. Helms, MD Angular cheilitis (AC) is a common condition char- cheilitis can evolve into diffuse cheilitis involving the acterized by erythema, moist maceration, ulcer- entire surface of the upper and lower lips. ation, and crusting at the corners of the mouth. Studies focusing on the prevalence of AC and its This article focuses on the common local factors etiologies are limited, but experience suggests that that act alone and in combination to produce AC. AC is associated with a variety of local and systemic These factors are categorized as irritant, allergic, factors that act alone and in combination. Local and infectious causes. Identifying the underlying factors (irritant, allergic, or infectious) are the most etiology of AC is a critical step in developing an common. The centerpiece of initial treatment is to effective treatment plan for this condition. neutralize the impact of specific local factors on the Cutis. 2011;87:289-295. barrier function at this anatomic site to mitigate what can become a chronic refractory condition. ngular cheilitis (AC), also known as angular Irritant Contact Dermatitis cheilosis, commissural cheilitis, angular sto- Angular cheilitis was shown to be related to irritants A matitis, or perlèche (from the French term in 22% of cases in one study (N5156).3 The skin pourlècher [to lick one’s lips]),CUTIS is characterized by at the corner of the mouth is subject to macera- inflammation of the vermilion commissures and adja- tion and digestion from salivary enzyme stasis with cent mucous membranes.1 Initially, the corners of the resultant inflammatory/irritant changes of greater mouth show a grayish white thickening with adjacent severity than elsewhere on the lips where saliva erythema. Acute AC can quickly evolve with worsen- contacts the skin for shorter periods of time.11 These ing erythema, moist maceration, ulceration, and crust enzymes include amylase, maltase, lipase, catalase, formation. In cases of long-term AC, granulation tis- sulfatase, hexokinase, carbonic anhydrase, and oth- sue Doforms and the adjacent skinNot often shows a scaly ers. 1 ProlongedCopy contact with these irritants is com- dermatitis.2 Patients report associated soreness, pain, monly associated with the anatomical changes that burning, or pruritus. Angular cheilitis can be unilat- produce a deeper than normal fold of skin at the eral or bilateral and occurs most commonly in the corners of the mouth (Table 1). Any factor that third, fifth, and sixth decades of life.3 It accounts for 0.7% to 3.8% of all oral mucosal lesions in adults and 0.2% to 15.1% of oral lesions in children.4-10 Angular All from the Dermatology Section, Northeastern Ohio Universities College of Medicine, Rootstown. Dr. Park also is from the University of California, San Francisco. Dr. Brodell also is from Case Western Reserve University School of Medicine, Cleveland, Ohio, and University of Rochester School of Medicine and Dentistry, New York. Dr. Helms also is from Case Western Reserve University School of Medicine. The authors report no conflict of interest. Correspondence: Kelly K. Park, MD, The Psoriasis & Skin Treatment Figure 1. An 80-year-old woman with angular (irritant) Center, Phototherapy & Clinical Research Unit, Department of cheilitis demonstrated loss of vertical dimension of the Dermatology, University of California, San Francisco, 515 Spruce St, mouth due to overclosure, chronic sun damage, and a San Francisco, CA ([email protected]). long history of cigarette smoking. WWW.CUTIS.COM VOLUME 87, JUNE 2011 289 Copyright Cutis 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Angular Cheilitis Table 1. Irritant Contact Dermatitis Causing Angular Cheilitis Category Etiologya Treatment Anatomical: modifications that Reduced vertical dimension, loss Decrease depth of angular facilitate increased exposure to of facial support skin fold with fillers or irritant(s); common in elderly, collagen injections debilitated, and/or malnourished patients Abnormal skeletal, tooth, and soft Assess need for dentures or tissue anatomy prosthetics with follow-up and maintenance, proper positioning of appliances Orthodontic/dental appliances Reassess proper fit, local preventive measures Weight loss, solar elastosis Local preventive measures Mechanical: redundant behaviors Tobacco use Cessation of tobacco use and actions that lead to irritation Trauma (eg, dental flossing) Switch to waxed dental floss CUTISand do not open mouth too widely Factitious/psychogenic Behavior modification, assess underlying psychiatric issues Do NotHabitual (eg, drooling, excessiveCopy Behavior modification, local salivation, lip licking, gum preventive measures chewing, onychophagia, thumb or object chewing/sucking) Dryness from mouth breathing Behavior modification, adequate moisturization Chemical: caustic factors leading Heat/thermal burns Avoid trauma to irritation Saliva (eg, pooling, altered Local preventive measures composition, or excessive production) Dental cleaning, denture cleaners Warm solutions of denture cleaner followed by thorough rinsing aDiagnosed by history and physical examination. 290 CUTIS® WWW.CUTIS.COM Copyright Cutis 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Angular Cheilitis reduces vertical dimension or facial support between Allergic Contact Dermatitis the mandible and maxilla leads to overclosure and When allergens come in contact with both the accentuation of this anatomic condition (Figure 1), oral mucosa and lips, they often produce cheilitis which may be a contributing factor in up to 11% of only.1,11 In addition, the presence of irritant AC AC in the elderly and up to 18% of AC in denture may predispose patients to a superimposed allergic wearers.5,12-14 Loss of vertical dimension also can be contact dermatitis due to increased penetration of associated with edentulousness, tooth migration, the allergens at this site.15 Thus a nickel-sensitive patient presence of orthodontic appliances, and elastic tissue with oral exposure to nickel-containing orthodontic damage caused by long-term UV light and tobacco braces may develop AC rather than diffuse cheilitis use. Clinically, AC due to irritants tends to be long or mucositis.16 Although patch test data involving term, bilateral, and associated with periods of relapse large series of AC patients are not available, stud- and remission.3 ies in patients with generalized cheilitis reveal up to Angular cheilitis caused by irritation is especially 22% of cases in the United Kingdom, 25% of cases in common in patients with eczema because of their sen- Australia, and 34% of cases in Singapore had an aller- sitive skin. In addition, drooling, excessive salivation, gic basis.17-19 Generalized cheilitis has been etiologi- and/or lip licking, as well as dental cleaning, lollipop cally related to regional allergic reactions to lipstick, sucking, gum chewing, persistent mouth breathing, toothpaste, acne products, cosmetics, chewing gum, thumb sucking, chewing or sucking on objects such as mouthwash, foods, dental appliances, and denture pencils or pipes, heat/thermal burns, denture cleaners, substrates or mercury amalgams (Table 2),1,16-22 which and trauma from dental flossing can initiate or aggra- is important when confronted with patients with AC vate AC. Factitious cheilitis, a psychogenic process because any substance that can cause allergic cheilitis produced when anxious individuals lick and/or pick at can produce angular involvement as the presenting the lips, also must be considered. It can be unilateral clinical picture. or bilateral and may last for just a few days or persist Allergic contact dermatitis often is impossible for months to years.3 CUTISto distinguish from irritant contact dermatitis using Table 2. Allergic Contact Dermatitis Causing Angular and Generalized Cheilitis1,16-22 TypeDoMost CommonNot Allergens CopyCommon Sources/Exposures Flavorings and Cinnamic aldehyde, oak moss, eugenol, Lip gloss, lipstick, lip balm, lip liner, fragrances isoeugenol, geraniol, methyl cinnamic cosmetics/makeup, aftershave, cologne, aldehyde, cinnamic alcohol, anethole, perfume, toothpaste, chewing gum, spearmint oil, peppermint, menthol, toothpicks, foods, ice cream, confectionery, carvone, propolis, essence of mint, cigarettes, soap, lotion, oral hygiene Myroxylon balsamum (balsam of Peru), products, liquors, dentifrices limonene, aniline dye, azo dye, FD&C yellow 11 Metals Nickel Orthodontic devices, dentures, dental instruments, lipstick casing, eyeglass frames, jewelry, pencils, pens, musical instruments Gold, mercury, palladium Fillings Potassium dichromate, cobalt Braces, bridges, retainers TABLE CONTINUED ON PAGE 292 WWW.CUTIS.COM VOLUME 87, JUNE 2011 291 Copyright Cutis 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Angular Cheilitis Table 2. (continued) Type Most Common Allergens Common Sources/Exposures Sunscreens Benzophenones, p-aminobenzoic acid Lipstick, lip balm, sunscreen Butyl methoxydibenzoylmethane Self-tanner Isopropyl dibenzoylmethane Foundation Phenyl salicylate (salol) Creams, hair products, lotions Preservatives, Propyl gallate Lipstick, cosmetics, foods antiseptics, and antioxidants Formaldehyde Nail polish Quaternium-15 Face powder,
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