Angular Cheilitis — Case History (Model Presentation)

Angular cheilitis (also called angular stomatitis, perleche, or commissural cheilitis) is inflammation at the corners of the mouth. Below is a representative case history format you can use for clinical documentation, case-based learning, or exam presentation, followed by the key teaching points.

Sample Case History

Patient particulars: 68-year-old female, denture wearer.

Chief complaint: Soreness, cracking, and redness at both corners of the mouth for 3 weeks, worse on opening the mouth or eating.

History of presenting illness:

Gradual onset of erythema and fissuring at bilateral labial commissures
Burning sensation, mild pain on mouth opening
Occasional bleeding from cracks when eating/talking
No improvement with lip balm alone

Past dental/medical history:

Complete upper and lower dentures for 10 years, not relined recently (reduced vertical dimension of the face)
Type 2 diabetes mellitus (poorly controlled, HbA1c 8.9%)
No history of smoking; occasional lip licking noted

Relevant systemic review: No weight loss, no oral ulcers elsewhere, no rash, denies dry eyes/dry mouth (rules against Sjögren syndrome as a driver), no recent antibiotic use.

Extraoral examination:

Bilateral fissuring, maceration, and erythema radiating from the labial commissures
Overclosure of the mouth with deepened folds at the corners consistent with lost vertical dimension
No lymphadenopathy

Intraoral examination:

Ill-fitting, worn dentures with reduced occlusal height
Erythematous, slightly atrophic palatal mucosa under the denture-bearing area (denture stomatitis)
No pseudomembranous plaques

Differential diagnosis:

Angular cheilitis (Candida albicans and/or Staphylococcus aureus superinfection)
Herpes labialis (recurrent)
Contact/allergic cheilitis
Nutritional deficiency (riboflavin/B2, B6, B12, iron)
Crohn disease-related orofacial granulomatosis
HIV-associated mucocutaneous disease

Investigations:

Swab/smear from commissures for fungal culture/KOH -> positive for Candida albicans
Random blood glucose / HbA1c (already elevated, confirming poor diabetic control)
CBC to screen for anemia/nutritional deficiency if history suggests it

Diagnosis: Angular cheilitis secondary to loss of vertical facial dimension (ill-fitting dentures) with candidal superinfection, in a patient with uncontrolled diabetes mellitus.

Management:

Topical antifungal-corticosteroid combination (e.g., nystatin with a mild-to-moderate topical steroid such as hydrocortisone or desonide) applied to the commissures
Denture adjustment/reline or new dentures to restore occlusal/vertical dimension; treat concurrent denture stomatitis
Improve glycemic control
If Staphylococcus aureus is co-isolated, add topical mupirocin
Barrier protection (petrolatum) between applications to reduce maceration from saliva
Follow-up in 2 weeks to assess response; if refractory, consider patch testing for allergic contact cheilitis, or in resistant/anatomically driven cases, filler (collagen/soft tissue implants) or surgical correction of the angular creases

Outcome/prognosis: Most cases resolve within 2-4 weeks with correction of the underlying cause (denture fit, glycemic control) plus topical therapy. Recurrence is common (reported as high as 80% in some series) if the underlying anatomical, nutritional, or infectious driver is not corrected.

Key Teaching Points (from the textbook literature)

Definition/synonyms: Angular cheilitis = perleche; fissures radiate outward from the labial commissures. It is an intertriginous dermatitis from excess wetness or dryness, often secondarily infected with Candida albicans or Staphylococcus aureus - Andrews' Diseases of the Skin, p. 917.
Classic population: Elderly denture wearers with reduced vertical facial dimension (overhanging upper lip/cheek, alveolar ridge atrophy). A simple ruler/tongue-blade measurement can objectively confirm decreased vertical dimension - Andrews' Diseases of the Skin, p. 917.
Other risk factors: Riboflavin deficiency, anorexia nervosa, Down syndrome, intraoral candidiasis (especially in diabetes or HIV/AIDS), chronic mucocutaneous candidiasis, Sjögren syndrome, orthodontic treatment, drug-induced xerostomia, atopic dermatitis, and in children, thumb-sucking, gum chewing, or lollipop habits - Andrews' Diseases of the Skin, p. 917.
Clinical appearance: Fissured, macerated, or erythematous labial commissures, sometimes extending onto adjacent skin; a Candida-related condition, occasionally coinfected with staphylococci - Cummings Otolaryngology, p. 1585.
Systemic associations: Listed as a clinical feature in WHO HIV clinical staging (Stage 2), nutritional deficiencies (riboflavin/B2, B6, B12), and Crohn disease oral manifestations - Park's Textbook of PSM, p. 5071; K J Lee's Essential Otolaryngology.
Treatment principles: Correct the underlying cause (denture fit/vertical dimension, glycemic control, nutritional repletion) plus topical antifungal +/- mild corticosteroid; add mupirocin if S. aureus is present; consider filler/surgical correction for anatomically resistant cases - Andrews' Diseases of the Skin, p. 917.

For evidence-based treatment nuance, a recent narrative review (Cabras et al., Oral Diseases 2020) supports the same stepwise approach: barrier protection, empiric antifungal/antibacterial therapy, and correction of predisposing mechanical/nutritional factors. My PubMed check for the last 2-3 years found no systematic reviews or meta-analyses specific to angular cheilitis treatment that would contradict this - the closest recent systematic reviews concern related but distinct entities (pigmented contact cheilitis, cheilitis glandularis, actinic cheilitis), so no evidence conflict to flag here.

If you want, I can tailor this case history to a specific patient scenario (e.g., pediatric, HIV-positive, or nutritional-deficiency-driven case) or turn it into a formatted document.

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