Angular cheilitis — also called angular stomatitis or perlèche — is an inflammatory condition affecting one or both corners of the mouth, causing painful cracking, redness and sometimes bleeding. It is surprisingly common and frequently presents at the pharmacy counter, where it is sometimes mistaken for cold sores or simple chapped lips.

What causes it

Angular cheilitis is typically caused by a combination of moisture accumulation at the mouth corners and secondary infection, usually by Candida albicans (a yeast), Staphylococcus aureus (bacteria), or both.

According to NICE CKS, predisposing factors include:

• Saliva pooling at the mouth corners — this is the most common trigger. It occurs in people with deep skin folds at the commissures (often age-related), habitual lip-licking, poorly fitting dentures, or excessive salivation.
• Nutritional deficiencies — iron deficiency, vitamin B12 deficiency and folate deficiency can all predispose to angular cheilitis by weakening the mucous membrane integrity.
• Immunosuppression — HIV, diabetes, oral corticosteroid use, chemotherapy.
• Antibiotic use — broad-spectrum antibiotics can disrupt oral flora and promote candidal overgrowth.
• Denture-related factors — ill-fitting dentures allow saliva to pool and create a moist environment where Candida thrives. Angular cheilitis in denture wearers often co-exists with denture stomatitis.
• Atopic dermatitis or contact dermatitis — lip cosmetics, toothpaste ingredients (sodium lauryl sulfate), or habitual use of lip balms containing potential sensitisers.

Pharmacy assessment

Before recommending treatment, pharmacists should consider:

1. Duration. Acute episodes (days to a couple of weeks) are usually straightforward. Chronic or frequently recurring episodes suggest an underlying cause that needs investigation.
2. Bilateral vs unilateral. Bilateral (both corners) is more common and usually suggests candidal infection or nutritional deficiency. Unilateral angular cheilitis can occur but should prompt consideration of other diagnoses (herpes simplex, squamous cell carcinoma in older patients).
3. Associated oral symptoms. White patches inside the mouth suggest oral candidiasis, which should be treated concurrently.
4. Denture use. Denture wearers with angular cheilitis often need both antifungal treatment and a dental referral for denture assessment.

Pharmacy treatment

Topical antifungal

For most presentations at the pharmacy counter, a topical antifungal is first-line:

• Miconazole 2% cream applied thinly to the corners of the mouth two to three times daily. Miconazole has both antifungal and antibacterial activity, making it effective against the mixed infections that typically cause angular cheilitis.
• Clotrimazole 1% cream is an alternative if miconazole is unavailable or not tolerated.

Treatment should continue for at least 7 days, and for 7 days beyond symptom resolution to prevent relapse — a total of approximately 2–3 weeks in most cases.

Important interaction: Miconazole (even topical) can enhance the anticoagulant effect of warfarin. Pharmacists should check medication history and advise warfarin users accordingly — clotrimazole is the preferred alternative in this group.

Barrier protection

Applying a thin layer of petroleum jelly (Vaseline) or a zinc-and-castor-oil barrier cream over the antifungal once it has absorbed helps protect the damaged skin from further moisture accumulation. This barrier function is as important as the antifungal itself — without it, the moist environment that caused the infection persists.

Lip care

• Advise against licking the lips, which perpetuates the moisture cycle.
• A bland, fragrance-free lip balm containing no potential sensitisers can be used on the lips themselves (not the corners) to prevent drying that leads to licking.
• Avoid flavoured or medicated lip balms during active angular cheilitis.

Managing denture-related angular cheilitis

For denture wearers, the pharmacy treatment is the same (miconazole cream to the corners), but the dentures themselves need attention:

• Remove dentures overnight and soak in chlorhexidine 0.2% solution or a proprietary denture cleanser.
• Apply miconazole oral gel (Daktarin, available P medicine) to the fitting surface of the denture before insertion — this treats concurrent denture stomatitis.
• Refer to a dentist for denture assessment if the fit has deteriorated.

When to refer

Pharmacists should refer to a GP if:

• Symptoms persist beyond 2–3 weeks of appropriate antifungal treatment.
• Recurrent episodes (three or more in 12 months) — blood tests for iron, B12 and folate are appropriate, and diabetes screening may be warranted.
• Unilateral persistent lesion in an older patient — to exclude squamous cell carcinoma or other malignancy.
• Suspected oral candidiasis (white patches inside the mouth) in a patient not taking inhaled corticosteroids — may indicate an underlying immunodeficiency.
• Significant pain or secondary bacterial infection — spreading redness, swelling or pus may need oral antibiotics.

Nutritional considerations

Iron and B12 deficiency are common in the UK. Pharmacists can advise patients with recurrent angular cheilitis to discuss blood tests with their GP. In the meantime, ensuring adequate dietary intake of iron (red meat, dark leafy greens, fortified cereals) and B12 (meat, dairy, fortified plant milks) is sensible advice, though supplementation without confirmed deficiency is not routinely recommended.

Finding pharmacy advice

Community pharmacists can assess and treat angular cheilitis without a GP appointment. Use PharmSee's pharmacy finder to locate a pharmacy near you, or explore pharmacy salary and career data if you work in the sector.

Sources: NICE CKS Oral Candidiasis, NHS Angular Cheilitis, BNF.