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What is angular cheilitis?
There is a multitude of names for angular cheilitis. It is known as, for example, angular stomatitis, perlèche, cheilosis etc. Its clinical picture is manifested by cracks, splits, and lesions along the corners of the mouth. These lesions are normally not too painful. Yet angular cheilitis turns often into a chronic status for many patients. The chronic status is characterized by recurrent outbreak of the disease, which lasts then from a couple of days up to several months. Although the lesions have the tendency of not being too painful, they can bleed with the opening of the mouth for eating, talking etc., ultimately forming a crust. Needless to say that these occurrences, bleeding mouth, crusted lips come hand in hand with a huge cosmetic deficit for the angular cheilitis patient.
What causes angular cheilitis?
As the word “cheilitis” already indicates, this disease is an inflammation of the lips (“cheilo-” stands for “lips”, and the ending “-itis” indicates the inflammatory process). This disease is very often triggered by a fungal infection, e.g. via Candida albicans, or different pathogenic microorganisms. The question remains, in how far an infection can be able to induce an often chronic status of inflammation? In order to get a firm grasp in understanding these processes, let’s take a look at the pathophysiology of inflammation.
“Inflammare” is the root word of “inflammation” and means: being put on fire or fired up. The inflammation itself is a complex bio-physiological response of vascular tissue to a nonphysiological occurrence, which comes to pass in case of an infection with viruses or bacteria, but also through cell damage or application of toxins. The body responds with the induction of an inflammatory process as an attempt to get rid of the cause of the nonphysiologic condition, at the same time starting repair mechanisms in the affected area. So inflammation and infection are not the same or synonymous. Both are interrelated, since inflammation is often induced by an infection, which has a different cause, mostly exogenous pathogens to which inflammation is one of the possible physiological responses.
Inflammation is a process with two faces. Without it, infections and infectious wounds are not very likely to heal, which would come with an ongoing destruction of tissue, organs, which would result in failure of the affected organ and also possible death of the patient if the destruction in the affected organ is severe enough. In other words, inflammation is a physiological defense mechanism, which protects us from harmful exogenous influences and repairs damages, which already have been occurring. If the process becomes chronic, on the other hand, it can become the breeding ground for new diseases, as we can see in asthma, rheumatoid arthritis, atherosclerosis, and some others; or our case for angular cheilitis. Our body seems to know that inflammation is a heavy answer to unphysiologic conditions, and therefore it monitors this process painstakingly, just to avoid exaggerated reactions and resulting additional problems.
We can categorize inflammation as acute and chronic. The acute inflammation marks the initial response of the body to unphysiologic events. This is accompanied by increased influx of plasma and leukocytes from the blood vessels towards the area of injury and then followed by a cascade of biochemical processes, which start and regulate the inflammatory answer. The local vascular apparatus in tandem with the immune system also play a major role in the regulation of the inflammation and direct impact on invading “foreign bodies.”
A prolonged inflammation is regarded as a chronic inflammation. Tissue, which is exposed to inflammatory processes for a longer period of time, reacts with a progressive shift in the kind of cells which occur in the area of inflammation. This results in the destruction and healing of affected tissues.
And this is exactly what happens in a chronic course of angular cheilitis. The inflammation recurs every now and then, giving room for the colonization of new pathogens, which on their part trigger new inflammatory bouts. We are dealing here with an impressive biological vicious cycle, where the question remains:
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Any additional factors which contribute to the contraction of angular cheilitis?
We already saw that infections, mostly by Candida albicans, and bacterial infections are the main reason for the outbreak of angular cheilitis. Since lips show no sweat glands and sebaceous glands and show also a completely different histophysiology compared with normal skin, we have to acknowledge that lip tissue is way more sensitive to external influence than our regular epidermis, since the protective mechanism for the epidermis are not given in lip tissue. This results in that nutritional deficiencies can also have an impact on the status of lip tissue. Best example known for this is the riboflavin (vitamin B2) deficiency.
Riboflavin is a micronutrient, which is important for a healthy status of the body. It shows an important impact on different cellular processes, but mainly on cellular energy production. Besides this, it plays an important role in the metabolism of fats, carbohydrates, and proteins as well. Ariboflavinosis marks the deficiency of riboflavin, and comes along with cracked lips, the inflammation of the inner lining of the mouth and even tongue, with a sore throat, and the outbreak of angular cheilitis. Other typical symptoms of ariboflavinosis are photophobia and scrotal dermatitis.
Another trigger factor for angular cheilitis is iron deficiency anemia. Most prominent reason for this is usually a poor diet, which causes in the very end a list of other problematic dysfunctions. Angular cheilitis is also related to zinc deficiency, another “product” of poor nutritional behavior. Angular cheilitis is also known to be associated with a triple complex of diseases, namely iron deficiency anemia, glossitis, and dysphagia, the so called Plummer-Vinson syndrome.
The loss of dentures, which is somewhat common in elderly generations, results in a loss of vertical dimension, which allows a kind of overclosure of the mouth. This physio-mechanical dysfunction can also trigger angular cheilitis. As we already discussed, lips are not as well protected as the normal epidermis, so cold weather in winter can cause cracked lips, which occurs predominantly in younger children. In order to get some relief, the person will start licking his/her lips, just to find out that the situation most likely will aggravate. This aggravation invites pathogens to enter the micro lesions, thus inducing angular cheilitis. But medicines are also found to be a triggering factor for the occurrences of angular cheilitis. Isotretinoin, Accutane, is a vitamin A analog and is used to treat severe acne, as well as chemotherapy for brain and pancreas cancer, and is known to induce angular cheilitis, yet in very rare cases.
Other not so often reasons for angular cheilitis are immunocompromised patients, since they lack the ability to develop an adequate immunologic response in case of infection in lip and mouth area. Statistically those patients undergoing head and/or neck radiation have a bigger chance of contracting the disease. Diabetes mellitus also “invites” the buildup of angular cheilitis, especially in case of a poor diabetes management.
Western medicine and its curative approach
As we have seen already, fungal and bacterial infections seem to be the causes of angular cheilitis. Therefore the western school medicine concentrates its efforts on the treatment or elimination of those pathogens. Local topical antiseptic ointments or creams are the means of first choice, which normally are efficient enough to contain the infection. Antifungal creams also show similar effects on fungal infections, and work well in minor cases. Within only a couple of days the infection will be contained.
To treat more severe cases is also more challenging. The severity of the case itself implies normally that an infection is not necessarily the only cause for angular cheilitis. Here a multitude of different triggering factors is more likely to be present, which will automatically complicate a proper treatment. In this case the doctor has to look also into the nutritional behavior of the patient, since ariboflavinosis, zinc deficiency and other forms of malnutrition could have a determining impact on the expression of the disease. This will explain why angular cheilitis is nothing but a symptom of a more severe underlying cause, which needs to be addressed so that the patient’s problem can be handled properly.
For example if one of the underlying causes is an ariboflavinosis, applying ointments alone will not be doing the trick. They will be able to cope some of the symptoms, but it is inevitable to do something about the deficiency by eating vitamin B2 rich food, like Asparagus and bananas, milk, cheese, meat, eggs, fish, and others. Riboflavin gets easily destroyed by ultraviolet light. Therefore milk in glass bottles will surely have less amounts of riboflavin than milk coming out of a solid opaque container.
In case of an iron deficiency, appropriate supplementation with iron sulfate, ferrous bisglycinate, and/or ferrous gluconate is the means of choice. But an iron supplementation has also its two faces, a beneficial one and a less beneficial one. High concentrations of iron generate a favorable environment for certain pathogens. It is known now that iron supplements for children brought out an increased occurrence of diarrhea and enteropathogen shedding. A deficiency, on the other hand, prevents the development of bacterial growth to a defined degree in predefined bacterial strains. But an iron deficiency generally results in a weakened responsiveness of the immune system and is inviting therefore a whole array of other pathogens to colonize on and in the weakened body.
A more severe scenario shows up when angular cheilitis is just a symptom of iron deficiency, which is just a symptom of a malfunctioning absorption of nutrients due to intestinal cancers or other gastrointestinal disorders of malignant nature, which induce chronic blood loss as a cause of the iron deficiency.
While the mild cases can be rather easily treated with ointments and creams, especially if the angular cheilitis occurs only sporadically, the chronic history of angular cheilitis points very often to a more severe underlying problem, which is not so easily to address due to its more complex nature.
The alternative approach for an angular cheilitis cure
As we have seen, angular cheilitis as a disease might be nothing but a symptom for something more severe. In this case it will make not much sense to treat cracked lips and inflamed mouths. This will be nothing but medicinal cosmetics, improving the looks but not the status of the patient. If the condition is that angular cheilitis occurs as a result of a more severe underlying cause, angular cheilitis itself is just a kind of “warning light.” Turning of warning lights is never advisable, since the cause will not be removed by doing so; and even worse, an unaddressed deeper problem will be ignored and can develop into something really dangerous, which might become incurable once the point of no return has been passed. A holistic approach should be serious about “warning lights,” and treat them as such, taking all the necessary factors into consideration, and finding the root of the problems.
Preventive measures have to play a predominant role applying holistic medicine. This has to be applied, regardless whether the disease has already fully developed or it is only in its beginning stage. These preventive measures will take care by avoiding setbacks and relapses once the therapy sets in to become efficient. Another point is, that the course of a relapse is usually more severe than the course of the previous attack. Avoiding relapses means avoiding a lot of particular trouble and pain (and ultimately expenses too). These preventive measures very often turned out also to be sufficient enough to contain the entire course of the disease and no additional intervention was necessary. Yet this does not mean to say that a symptomatic intervention would be wrong. Cracked lips, inflamed mouths, sometimes even bleeding, etc. is a significant cosmetic handicap, which might prevent the patient to take part in normal social life. These ointments and creams do a great job most of the time to handle the symptoms of angular cheilitis and thus enhancing also the well-being of the patient.
This marks the start of a holistic treatment. It finds its continuation in a good nutrition, since a good nutrition often plays an important role in the prevention of other diseases and angular cheilitis. This will enhance the patient’s immune system, a factor which gains in importance, since we discussed earlier that angular cheilitis patients contract their disease due to a sluggish immune status. Also here a riboflavin enriched food has to be given preference, in combination with food high in iron. This regimen will guarantee in most of the cases that nutritional deficiencies are to be excluded from the list of possible causes.
A very crucial way to avoid malfunction of absorption in small and large intestines is the prioritization of vegetarian food with focus on sufficient fibers. The connection between angular cheilitis and fiber-rich food might be unclear at first sight. But fibers are essential for the survival of certain microorganisms inside the gastrointestinal tract, which execute important tasks in terms of vitamin absorption and equilibration of the entire GI environment. A lack of fibers promises a reduction of these advantageous microorganisms, which triggers an absorption deficiency, which translates into malnutrition after some period of time. And this will be the time when angular cheilitis starts to occur on a more permanent basis.
An almost perfect holistic way to influence immune system, exert positive effects on the GI environment, remove possible toxins (free radicals, peroxides), provide essential nutrients and more, is the application of medicinal mushrooms from the traditional Chinese medicine. The most prominent medicinal mushroom is Ganoderma lucidum, which can do all this. Medicinal mushrooms are able to balance the immune system, in order to create a hemostatic condition. They have also proven that they have excellent antiinflammatory properties, a fact, which will be of interest for the angular cheilitis patient, who regularly suffers from inflamed lips (sometimes even the tongue is included in the process). In other words, medicinal mushrooms are a kind of “super food,” which deliver all the nutrients for a healthy overall status and are able to exert medicinal properties, which are beneficial for angular cheilitis patients.
Which way to go? Go West or Holistic?
Both disciplines show a lot of advantages in the field of medicine. Western school medicine is well equipped when it comes to the management of emergency situations. Surgery often comes in as a life-saving intervention; normally deadly infections are fended off by the application of antibiotics. These areas reveal comparatively fast results and high success rates. This might also be one of the reasons why most people rather consult a western medicine doctor than trusting his eastern counterpart.
On the other hand, the so-called “civilization” diseases, as there are hypertension, caries, diabetes, hypercholesterolemia, hyperlipidemia, obesity, cardiovascular diseases, resulting in stroke, myocardial infarction, nephropathy etc. are more than a tough challenge for the western school medicine. In many cases, these diseases are pronounced as not curable. So western school medicine limits itself to a mere disease and symptoms management, a procedure which guarantees profitable markets for the pharmaceutical industry, since all these patients are life-long, long-term patients or paying customers. Yet weight reduction in combination with some sort of physical exercise, supported by a healthy diet can do much about hypertension, hyperlipidemia, hypercholesterolemia, some nervous disorders, like sleep disorders, or at least can improve the overall situation for a long period of time.
But what is the connection to angular cheilitis? This disease pops up once in awhile or more on a frequent basis. If the occurrence is more frequent, there is reason to assume that a more serious underlying cause is playing an important role in the pathogenesis of angular cheilitis. In order to get hold of the entire disease process, the physician has to evaluate these causes or the patient will be coming to the clinic every now and then because of new bouts of his problem. But daily praxis is that the patient will leave the consultation room with a prescription of a cortisol product, in order to fight the inflammation. Inflammation thus is not the big deal, since it is a natural reaction to something going bad inside the body. No doubt that antifungal, antiinflammatory, and antibiotic creams and ointments will bring relief to the patient. Stopping here with the treatment will ensure that the patient will be coming back again, at least when a new bout of angular cheilitis pesters him. A holistic concept will treat the symptoms, and then look further into the dietary conditions, and makes sure that severe hidden causes are to be excluded, where angular cheilitis presents only as a “symptom” of this possible way more severe cause.
In case of an underlying dietary deficiency, it is by far more advisable to resort to natural products rather than artificially generated products produced by the chemical industry. Natural products are balanced in their ingredients and bioavailability mostly is also much higher than the bioavailability of their chemical counterparts. If the symptomatic treatment tries to replace the holistic approach, it will be very likely that the symptomatic application of cortisone, for example, will become a never ending affair, bringing along as a long-term effect a possible additional medicinal problem, since a permanent application of the “symptom killers” is not without effect also on the entire body. Our patient might end up still sporting his angular cheilitis, but with additional problems deriving from extensive cortisone use over the years. In other words, there is also the need to be careful with agents which deal with angular cheilitis symptoms. Lip sticks, moisturizers and more should be chosen very carefully, making sure that they are free from artificial and potentially dangerous ingredients. Cortisone containing products for a long-term application are definitely obsolete, since their negative long-term effects are well reported meanwhile. It might take some time until the right tools, also for the symptomatic therapy are found for the patient.
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