Pathology · patient case question
Her commissures are cracked and erythematous. This finding is best explained as:
Patient case: The mouth that will not stay wet
demo: 54-year-old female
chief: Burning, sticky mouth for the past eight months; food gets caught and she wakes at night to sip water.
history: Hashimoto thyroiditis. Her rheumatologist ordered an autoantibody panel after she reported gritty, burning eyes.
meds: Levothyroxine 75 mcg daily. Amitriptyline 25 mcg at night for chronic tension headache.
findings: Anti-SSA (Ro) strongly positive. Salivary pooling is absent; the mucosa is dry and the tongue is fissured with papillary atrophy. Cracking and erythema at both commissures. Two new cervical lesions since her last visit a year ago.
Show answer and explanation
Correct answer: C. Angular cheilitis secondary to xerostomia and Candida overgrowth
- A. Squamous cell carcinoma of the commissure would be an indurated ulcer or exophytic mass, not symmetrical bilateral fissuring, and it would not be the first consideration in this setting.
- B. Herpes labialis produces a vesicular then crusted lesion on the vermilion border, is usually unilateral, recurs at the same site and is preceded by prodromal tingling.
- C. Correct. Reduced salivary flow removes antimicrobial proteins and permits Candida overgrowth; saliva pooling in the commissural folds keeps the tissue macerated. Candida albicans, often with Staphylococcus aureus, produces the fissuring and erythema. Treat the dryness and the candidal component together.
- D. An allergic contact reaction is typically more diffuse across the lips and perioral skin with itching, and would not localise so precisely to both commissures.