Pictorial case study: Painful sores

An elderly man had painful cracks at the corners of his mouth. By Dr Jean Watkins

An elderly patient was having trouble with sores at the corners of his mouth (Photograph: SPL)
An elderly patient was having trouble with sores at the corners of his mouth (Photograph: SPL)

 

The presentation

This elderly man had been having trouble with sores at angles at both corners of his mouth for some time. The area seemed to be constantly moist with painful cracks that bled from time to time; of late, they had been much more troublesome. Apart from recently diagnosed late-onset diabetes, he was otherwise well, maintained a healthy lifestyle and led an active life.

The management

A diagnosis of angular stomatitis of the lips was made.

Management involves dealing with any possible underlying causes. For example, dry lips can be helped by the regular application of an emollient such as soft white paraffin, and advice to not lick the lips too often.  A secondary fungal or bacterial infection may need to be managed. For those on a poor diet, nutrition supplements could be recommended and an FBC and B12 and folate would identify any anaemia that would require attention. A dentist may be required to help with any ill-fitting dentures.

Discussion

This is most common in the elderly, in whom loss of teeth and poorly fitting dentures alter the closure of the mouth and sagging skin develops around the mouth. Dry lips may occur in eczema, or those on medication such as isotretinoin that dries the skin; lip licking often aggravates the problem. Poor nutrition and conditions such as anorexia or bulimia may be a cause if there is a folate, B12 or iron deficiency anaemia. Other systemic problems that may be associated are diabetes, Sjögren's syndrome or HIV, oral corticosteroids, ulcerative colitis or Crohn’s disease. Secondary infection of the sores frequently occurs, most commonly with candida, but sometimes there is a bacterial infection.

Differential diagnosis

  • Actinic chelitis
  • Allergic contact dermatitis
  • Dry lips – eczema, lip licking or effect of medication such as isotretinoin
  • Herpes simplex
  • Malignancy (if concern about persistent ulceration)

Dr Watkins is a retired GP in Hampshire

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