Angular Cheilitis: What to do when faced with infected chapped lips?

Angular cheilitis, also known as perlèche, is an inflammation of the corners of the mouth. The most common cause is usually an infection. The pathogen most often responsible is Candida albicans, found in 93% of perlèche cases. However, it is rare for this yeast to be the only microorganism involved in the onset of angular cheilitis, as in 60 to 80% of cases, it is coupled with the bacterium Staphylococcus aureus. It can also happen that the infection is solely due to bacterial colonisation: it is estimated that 8 to 15% of perlèche cases follow a beta-hemolytic streptococcus. Finally, in addition to bacterial or fungal infections, the herpes simplex virus can also cause forms of recurrent cheilitis. It should be noted, however, that while perlèche is most often due to an infection, other causal factors are possible.

The first instinct when experiencing angular cheilitis should be to consult a healthcare professional.

The treatment of angular cheilitis and chapped lips that are infected depends on the origin of the disease, whether it is infectious or not. Given the predominance of the infectious cause, empirical management prioritises infections, particularly those caused by Candida albicans. Therefore, as a first step, the doctor usually advises applying an antifungal cream two to three times a day for two weeks. In moderate to severe cases, when the lesion extends to the oral cavity or in the absence of a response to local treatment, an oral antifungal is prescribed. Just like for topical antifungals, the oral medication is to be taken for 14 days. If the patient wears a dental prosthesis, it too will need to undergo antifungal treatment.

Like all medications, the use of antifungal drugs requires precautions, particularly due to possible drug interactions. One of the most commonly prescribed antifungals is fluconazole, often more effective than nystatin in immunocompromised patients. However, fluconazole is contraindicated with domperidone, a medication used to relieve nausea and vomiting, due to the risk of cardiac disorders posed by this combination. As for nystatin, its effectiveness can be reduced by certain laxatives, such as macrogol. Therefore, antifungal drugs must be prescribed according to the needs of the patients and taking into account any other treatments they may be undergoing, in order to avoid drug interactions.

In the event of antifungal treatments failing, a bacterial origin of angular cheilitis is then assumed and an antibiotic cream to be applied locally four times a day for one to two weeks is prescribed. A significant improvement in symptoms should be observed at the end of this period. If the bacteria Staphylococcus aureus is involved, a specific decolonisation treatment can be undertaken, particularly through the use of antistaphylococcal ointments applied in the nostrils, an area where the bacteria is frequently present. Oral antibiotic therapy is rarer and reserved for cases where the lesion is extensive or persists despite local treatment. Studies report that the sources of failure of this treatment are the presence of resistant germs or the neglect of risk factors that maintain the infection.

Finally, if angular cheilitis has a viral origin and is due to the herpes simplex virus, the management involves the administration of antivirals, in the form of creams or tablets, depending on the severity of the infection. The main antivirals used to combat this type of virus are aciclovir, valaciclovir or famciclovir. They aim to inhibit the multiplication of the virus and to reduce the duration and severity of symptoms. It should be noted that it is essential to start antiviral treatment as soon as possible, from the first signs of lesion appearance, for maximum effectiveness. Patients should also be informed that certain factors can reactivate the herpes simplex, such as stress or weakened immunity. Preventive measures, established on a case-by-case basis by the doctor, can therefore be suggested.

In rarer instances, angular cheilitis can be associated with underlying medical conditions, such as diabetes or Sjögren's syndrome, which require overall management. Only a medical consultation can confirm this, hence the importance of seeking a doctor's opinion in the case of angular cheilitis.