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Scenario

Linda McKay has come into the pharmacy and smiles, then winces, when she sees pharmacy technician Vicky at the counter.

“I’m wondering if you can help me,” Linda starts. “I’ve got this little spot or cut at the side of my mouth, and it’s driving me crazy!”

“How long has it been there?” asks Vicky, leaning over the counter for a closer look.

“A few days,” replies Linda. “It’s right in the corner, so every time I open my mouth wide – if I eat or smile, basically – I can feel it crack open again. I know it looks tiny, but honestly, it’s really quite painful.”

“Have you had anything like this before?” queries Vicky. “And have you tried anything for it? You don’t take anything other than those vitamin D tablets we dispense for you, do you? I take it nobody else in your family has got the same thing?”

“Nope, it’s just the vitamin D I’m on and it’s just me that seems to have it,” says Linda. “I’ve tried a lip balm for this, but it isn’t really doing anything. I had the same thing a couple of months ago, and I don’t really remember what helped it go. Someone said that it might be a sign I’m low in vitamin C – do you think that could be the case?”

Answer

Linda may have angular chelitis – sometimes known as angular stomatitis – which is inflammation of the skin at the corner of the mouth. The symptoms can include redness, cracking, scaling, bleeding and ulceration at one or both corners of the mouth, and there are various factors that increase the chance of it occurring, from wearing dentures and other oral appliances such as braces, contact allergies and nutritional defi ciencies, to dry skin and dermatitis. It is also more common in individuals who tend to have wetter lips – for example, a child who sucks their thumb, an older person who has a propensity to drool, or someone who is a bit over-zealous about using mouthwash – and those who have a compromised immune system, for instance, patients with HIV. In many cases, microorganisms are present, most commonly the fungi Candida or bacteria in the Staphylococcus or Streptococcus families; the latter can usually be diagnosed by the presence of crusting, though sometimes swabs will be taken for testing.

Treatment depends on the cause, so if dentures or braces are implicated, the patient should have the fi tting checked. If hypersalivation is an issue, breaking the habit or using emollients can be all that is needed. Miconozole cream is the topical product of choice otherwise, as it works against fungal infections and has some bacteriostatic action, though this may need stepping up to a formulation that includes a topical steroid and/or antibacterial agent, or oral antifungals, if needed.

The bigger picture

In the UK, nutritional deficiencies are usually only considered as a factor underpinning angular chelitis if other treatments seem to have not worked. Blood samples are taken and tested for glucose (as diabetes can compromise the immune system), iron, folic acid and vitamin B12. Correcting a deficiency is usually enough to prevent the problem recurring in the future.

This is also a good opportunity to provide some advice on basic lip care. Products containing petroleum jelly or beeswax are good choices for those who suffer from dry or sore lips, as they act as a barrier to trap moisture and protect against infection. Stick products are better than pots as they don’t require fingers to be used for application and therefore there is a reduced chance of microorganisms being introduced. Individuals who spend a lot of time outside should seek out a product with a sun protection factor of at least 15. And licking lips should be discouraged, as it removes the skin’s natural oils, exacerbating the issue.

Extend your learning

• See what angular chelitis looks like with the photos hosted by the Primary Care Dermatology Society
• Find out which mouthwash may be recommended for this condition by reading the leaflet produced by Sheffield Teaching Hospitals NHS Foundation Trust
• Patients with asthma are more prone to angular chelitis. Why do you think this is, and what can be done about it? Check your answers by reading the information from the PMC.