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Chancroid

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Saturday, January 01, 2011

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Case Note

Case Note: Persistent ‘lip ulcers’

History

A 68-year-old healthy female, with no significant past medical history presents for evaluation and management of persistent 'lip ulcers'. It is noted that the patient is edentulous and has ill-fitting dentures.

Initial evaluation

  • Healthy-appearing female
  • Peri-oral, erythematous crusted papules, with erythema and fissuring at bilateral lateral oral commissures
  • No evidence of oral candidiasis on exam
  • Image 1
    Image 1

Enter your diagnosis

Diagnosis

  • A diagnosis of angular cheilitis is rendered

Initial Treatment

  • Nystatin ointment or imidazole cream three times a day to affected areas for two weeks
  • Recommendation:
    • Frequent application of barrier ointment (petrolatum) throughout the day to avoid on-going maceration
    • Soaking dentures nightly in appropriate denture disinfecting solution
  • Referral to dentist for denture-fitting

Follow-up evaluation strategy

  • Follow-up in two weeks (patient was much improved)

General discussion

Angular cheilitis, also known as perlèche, is due to a combination of local irritation, moisture, and overgrowth of microorganisms, especiallyCandida albicansat the corners of the mouth. It primarily affects the lateral oral commissures with typically symmetric involvement.

In early stages, the affected skin is ill-defined and macerated, with superficial erythema and erosions. As the condition develops, skin lesions may become more papular, eczematous, crusted, and may develop fissures.

It is seen in five settings: infants; edentulous persons (usually in the elderly); adolescents and adults who wear orthodontic devices; diabetics and those who have undergone antibiotic or systemic steroid therapy; and immunosuppressed persons.

Any treatment plan should address microbial overgrowth at the affected site(s), as well as concomitant treatment of co-existing thrush if present. Failure to identify oral thrush may result in rapid relapse of the angular cheilitis. Since angular cheilitis stems from chronic maceration by saliva, it is also essential to minimise exposure to moisture by the use of a barrier ointment. 

Further reading

Park KK, et al. Angular cheilitis, part 1: local etiologies. Cutis 2011;87:289-95.

Park KK, et al. Angular cheilitis, part 2: nutritional, systemic, and drug-related causes and treatment. Cutis 2011;87:27-32.

Sharon V, Fazel N. Oral candidiasis and angular cheilitis. Dermatologic Therapy 2010;23:230-42.

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