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Malt liquor
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A 12oz (355mL) longneck beer bottle (left) and a 40oz (1183 mL) bottle of malt liquor
Malt liquor, in North America, is beer with high alcohol content. Legally, it often includes any alcoholic beverage with 5% or more alcohol by volume made with malted barley. In common usage, it refers to beers containing a high alcohol content, generally above 6%, which are made with ingredients and processes resembling those for American-style lagers.
Contents
[hide]
1 Manufacture
2 Brewing and legal definitions
3 History
4 Advertising
5 Forty-ounce
6 International
7 See also
8 References
9 External links
Manufacture[edit]
Malt liquor is a strong lager or ale in which sugar, corn or other adjuncts are added to the malted barley to boost the total amount of fermentable sugars in the wort, and thus boost the final alcohol concentration without creating a heavier or sweeter taste. These beers tend to be mildly hopped; that is, they are not very bitter.
Brewing and legal definitions[edit]
Malt liquor is typically straw to pale amber in color. While typical beer is made primarily from barley, water, and hops, malt liquors tend to make much greater use of inexpensive adjuncts such as corn, rice, or dextrose. Use of these adjuncts, along with the addition of special enzymes, results in a higher percentage of alcohol than an average beer. Higher alcohol versions, sometimes called "high-gravity" or just "HG", may contain high levels of fusel alcohols, which gives off solvent- or fuel-like aromas and flavors.[1]
The confusing and inconsistent use of the term "malt liquor" has to do with the vagaries of American alcoholic beverage regulations, which can vary from state to state. In some states, "malt liquor" refers to any alcoholic beverage made by fermenting grain and water; in these states a non-alcoholic beer may also be called a non-alcoholic or non-intoxicating malt liquor. In some states, products labeled "beer" must fall below a certain alcohol content, and beers that exceed the mark must be labeled as "malt liquor". While ordinary beers in the United States average around 5% alcohol by volume, malt liquors typically range from 6% up to 9% alcohol by volume. A typical legal definition is Colorado's Rev. Stat. ss. 12-47-103(19), which provides that:
"Malt Liquors" includes beer and shall be construed to mean any beverage obtained by the alcoholic fermentation of any infusion or decoction of barley, malt, hops or any other similar products, or any combination thereof, in water containing more than three and two-tenths percent of alcohol by weight.
Alcohol percentages measured by weight translate into larger figures when re-expressed as alcohol percentages by volume, because ethanol is less dense than water.
History[edit]
The term "malt liquor" is documented in England in 1690 as a general term encompassing both beer and ale.[2] The first mention of the term in North America appears in a patent issued by the Canadian government on July 6, 1842, to one G. Riley for "an improved method of brewing ale, beer, porter, and other maltliquors."
While Colt 45, St. Ides, Mickey's, Steel Reserve, King Cobra, and Olde English 800 are most closely associated with malt liquors in the United States, the beverage itself is older than these products. Clix is often credited as the first malt liquor made in the United States, granted a patent in 1948.[3] The first widely successful malt liquor brand in America was Country Club, which was produced in the early 1950s by the M. K. Goetz Brewing Company in St. Joseph, Missouri.
Advertising[edit]
See also: Alcohol advertising
The core market for malt liquor brewers in the United States has been the African-American and Hispanic populations.[4] Brewers' use of target marketing in advertising malt liquor primarily to young, inner-city, African-American males has been controversial, due to the drink's higher alcohol content and the perceived vulnerability of the target audience. Brewers and advertisers have stated that they simply advertise to those who already buy their products. Critics have objected to the targeting of a segment of the population suffering disproportionately from alcohol-related disease and poor access to medical care.[5]
In order to highlight the potency of malt liquor, brand names have stressed powerful imagery such as Colt 45, Big Bear, and Power Master,[6] and used slogans such as "It's got more" or "The Real Power".[7] Power and sexual dominance have been common themes in advertising.[6][8] Ads for Power Master were eventually banned in the United States due to regulations against advertising the strength of alcoholic beverages.[4][9][10]
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has reported that African Americans suffer disproportionate rates of cirrhosis of the liver and other alcohol-related health problems. In light of such statistics, African-American community leaders and some health officials have concluded that targeting high-alcohol beverage ads at this segment of the population is unethical and socially irresponsible.[5][10] In 1991, U.S. Surgeon General Antonia Novello criticized all alcoholic beverage companies for "unabashedly targeting teenagers" with "sexual imagery, cartoons, and rock and rap music" in television and print ads.[5]
Forty-ounce[edit]
In the American vernacular, a forty-ounce or simply forty is a glass or plastic bottle that holds 40 fluid ounces (1.18 litres, or 2.5 U.S. pints) of malt liquor.[1] Malt liquors are commonly sold in 40 fluid ounce bottles, among other sizes, as opposed to the standard twelve ounce (355 mL) bottle that contains a single serving of beer, although many malt liquors are offered in varying volumes.
After the introduction of 40-ounce containers, which contain roughly the same amount of alcohol as five regular cocktails, "40s" became a favorite high of many youth in inner-city areas. When American suburban youth adopted the habit of drinking malt liquor, drug counselors began to refer to "40s" as "liquid crack" and "date-rape brew".[7]
Examples of malt liquors sold in forty ounce bottles include Olde English 800, Colt 45, Mickey's, Camo 40, Black Fist, Country Club, Black Bull, Labatt Blue Dry 6.1/7.1/8.1/9.1/10.1, WildCat, Molson Dry 6.5/7.5/8.5/10.1, Private Stock, Big Bear, St. Ides, Steel Reserve 211, B40 Bull Max, King Cobra, Jeremiah Weed, and Hurricane. Dogfish Head Brewery has sporadically produced a high-end bottle-conditioned forty called "Liquor de Malt".[11] Ballantine markets its ale in a forty-ounce bottle as well.
Forties are often mentioned in hip-hop and rap culture by rap stars endorsing the "40" Ounce tradition. A similar trend was common around the late 1990s' and early 2000s' punk scene, with such songs as "40.oz Casualty" by The Casualties and "Rock the 40. Oz." by Leftöver Crack; and "40oz. to Freedom" by Sublime.
At least for a brief period in the mid-1990s, some brands of malt liquor, including Olde English 800, Colt 45, and Mickey's, were available in even larger, 64-ounce glass bottles. Forty-ounce bottles are not permitted in some US states, such as Florida, where the largest container that a malt beverage may be sold at retail is 32 US fluid ounces.[12]
International[edit]
While American malt liquor brands are rarely, if ever, exported to Europe, similar inexpensive high-alcohol beers are available in many areas there; these include the "super-strength lagers" such as Tennent's Super and Carlsberg Special Brew in the United Kingdom, and in France the "bières fortes" Amsterdam Navigator, Amsterdam Maximator and Bavaria 8.6; Arboga 10.2% of Sweden or Olvi Tuplapukki and Karhu Tosi Vahva in Finland.
Another example of an imported beer labeled as "malt liquor" is German brewer Spaten's Optimator, a doppelbock that weighs in at 7.6 ABV.
There was a short lived fashion for brewing American style malt liquors in Britain in the late 1970s and early 1980s. Some of these were genuine American brands brewed under license, notably Colt 45, and some were simply inspired by the style. They generally contained 5% ABV. These beers were heavily marketed for a few years but failed to make a lasting impact and are no longer produced.
See also[edit]
Flavored fortified wines
References[edit]
^ Jump up to: a b Breaking Out the Forty Archived 2013-08-22 at the Wayback Machine. Beer Advocate.com. March 21, 2001. Accessed on December 16, 2007.
Jump up ^ Saunders, John (1847). The People's Journal. People's Journal. p. 252. Retrieved 23 July 2011.
Jump up ^ Clix Patent Filing United States Patent and Trademark Office. Accessed December 20, 2007.
^ Jump up to: a b Mittelman, Amy (2008). Brewing Battles: A History of American Beer. Algora Publishing. p. 197. ISBN 9780875865744.
^ Jump up to: a b c Davidson, D. Kirk (2003). Selling Sin: The Marketing of Socially Unacceptable Products. Greenwood Publishing Group. pp. 113–5. ISBN 9781567206456.
^ Jump up to: a b Bowie, Norman E.; Schnieder, Meg (2011). Business Ethics For Dummies. John Wiley & Sons. ISBN 9781118020623.
^ Jump up to: a b Shaw, William H. (2013). Business Ethics: A Textbook with Cases. Cengage Learning. p. 311. ISBN 9781285415178.
Jump up ^ Cortese, Anthony J. (2007). Provocateur: Images of Women and Minorities in Advertising. Rowman & Littlefield Publishers. p. 123. ISBN 9780742568761.
Jump up ^ Shimp, Terence A.; Andrews, J. Craig (2012). Advertising Promotion and Other Aspects of Integrated Marketing Communications. Cengage Learning. p. 98. ISBN 1133709389.
^ Jump up to: a b Brenkert, George G. (2014). "Marketing to Inner-City Blacks: PowerMaster and Moral Responsibility". In Hovland, Roxanne; Wolburg, Joyce M.; Haley, Eric E. Readings in Advertising, Society, and Consumer Culture. Routledge. p. 275. ISBN 9781317461364.
Jump up ^ Liquor de Malt Dogfish Head Brewery. Accessed on March 27, 2008.
Jump up ^ Florida Statutes, Title XXXIV, Chapter 563; see item (6)
External links[edit]
Database of 40s
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Megalopyge opercularis
From Wikipedia, the free encyclopedia
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Megalopyge opercularis
Scientific classification
Kingdom: Animalia
Clade: Euarthropoda
Class: Insecta
Order: Lepidoptera
Family: Megalopygidae
Genus: Megalopyge
Species: M. opercularis
Binomial name
Megalopyge opercularis
(JE Smith, 1797)
Synonyms[citation needed]
Phalaena opercularis Smith, 1797[1][2]
Megalopyge albizona Dognin, 1923
Megalopyge bissesa Dyar, 1910
Megalopyge briseis Dyar, 1910
Megalopyge costaricensis Schaus, 1912
Megalopyge govana Schaus, 1904
Megalopyge incachaca Schaus, 1927
Pimela lanuginosa Clemens, 1860
Lagoa ornata Druce, 1887
Megalopyge opercularis is a moth of the family Megalopygidae. It has numerous common names, including southern flannel moth for its adult form, and puss caterpillar, asp, Italian asp, woolly slug, opossum bug,[3] puss moth, tree asp, or asp caterpillar for its larval form.
Contents
1 Description
2 Habitat
3 Dangers and treatment of stings
4 References
5 External links
Description[edit]
A M. opercularis caterpillar on Kent Island, Maryland.
Cocoon
The inch-long larva is generously coated in long, luxuriant hair-like setae, making it resemble a tiny Persian cat, the characteristic that presumably gave it the name "puss". It is variable in color, from downy grayish white to golden brown to dark charcoal gray. It often has a streak of bright orange running longitudinally. The "fur" on early-stage larvae is sometimes extremely curly, giving the larva a cottony, puffed-up look. The body tapers to a tail that extends well beyond the body, unlike its relative M. crispata.[4] The middle instar has a more disheveled, "bad-hair-day" appearance, without a distinctive tail. The "fur" of the larva contains venomous spines that cause extremely painful reactions in human skin upon contact. The adult moth is covered in long fur in colors ranging from dull orange to lemon yellow, with hairy legs and fuzzy black feet.
Habitat[edit]
Megalopyge opercularis can be found on oaks, elms, wild plum among others, as well as many garden plants such as roses and ivy. It is distributed throughout the eastern United States between extreme southeastern Virginia and Florida, the southern United States, Mexico, and parts of Central America.[5]
Dangers and treatment of stings[edit]
The caterpillar is regarded as a dangerous insect because of its venomous spines. Exposure to the caterpillar's fur-like spines will lead to an immediate skin irritation characterised by a, "grid-like hemorrhagic papular eruption with severe radiating pain". The pain has been described by patients as similar to a broken bone or blunt force trauma.[3] The reactions are sometimes localized to the affected area but are often very severe, radiating up a limb and causing burning, swelling, nausea, headache, abdominal distress, rashes, blisters, and sometimes chest pain, numbness, or difficulty breathing.[6][7] Additionally, it is not unusual to find sweating from the welts or hives at the site of the sting.
Medical advice may be sought in case of contact with one. It is best if the venom from the spines is treated within hours of first contact. For first aid, it is recommended that the spines (if present) be removed by using cellophane tape.[6] Some remedies, which are reported to have varying degrees of success, include ice packs, oral antihistamine, baking soda, hydrocortisone cream, juice from the stems of comfrey plants, or calamine lotion.[6]
References[edit]
Jump up ^ Smith, James Edward (1797). "Tab. LIII. Phalæna opercularis". The Natural History of the Rarer Lepidopterous Insects of Georgia. Including their systematic characters, the particulars of their several metamorphoses, and the plants on which they feed. Collected from the observation of Mr. John Abbot, many years resident in that country. 2. London: T. Bensley. pp. 105–106.
Jump up ^ Simmons, Alvin M.; Wiseman, B. R. (1993). "James Edward Smith - Taxonomic Author of the Fall Armyworm". The Florida Entomologist. 76 (2): 275. JSTOR 3495726.
^ Jump up to: a b Hossler, Eric W. (2009). "Caterpillars and moths". Dermatologic Therapy. 22 (4): 353–366. doi:10.1111/j.1529-8019.2009.01247.x. PMID 19580579.
Jump up ^ Wagner, David L. (2005). "Flannel Moths – Megalopygidae" . Caterpillars of Eastern North America. Princeton Univ. Press. p. 55.
Jump up ^ McGovern, John P.; Barkin, Gilbert D.; McElhenney, Thomas R.; Wende, Reubin (1961). "Megalopyge opercularis: Observations of Its Life History, Natural History of Its Sting in Man, and Report of an Epidemic". JAMA. 175 (13): 1155–1158. doi:10.1001/jama.1961.03040130039009.
^ Jump up to: a b c Eagleman, David M. (2007). "Envenomation by the asp caterpillar (Megalopyge opercularis)". Clinical Toxicology. 46 (3): 201–205. doi:10.1080/15563650701227729. PMID 18344102.
Jump up ^ Demkovich, Laurel (June 20, 2018). "'BE AWARE': Pasco mom posts to Facebook after son's caterpillar sting leads to ER trip". Tampa Bay Times. Retrieved 2018-06-21.
External links[edit]
Data related to Megalopyge opercularis at Wikispecies
Media related to Megalopyge opercularis at Wikimedia Commons
Research on the Asp Caterpillar at Baylor College of Medicine
Info page with photos
BugGuide account
Megalopyge opercularis on the UF / IFAS Featured Creatures website.
Taxon identifiers
Wikidata: Q4043912
BAMONA: Megalopyge-opercularis
BugGuide: 4476
EoL: 380025
EPPO: MEGAOP
GBIF: 1751572
iNaturalist: 84185
IRMNG: 10333838
LepIndex: 75422
NCBI: 1113279
Retrieved from "https://en.wikipedia.org/w/index.php?title=Megalopyge_opercularis&oldid=856781881"
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Moths described in 1797
Megalopygidae
Venomous insects
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Angular cheilitis
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Angular cheilitis
Synonyms
Rhagades,[1] perlèche,[2] cheilosis,[2] angular cheilosis,[2] commissural cheilitis,[2] angular stomatitis[2]
Bilateral angular cheilitis in an elderly individual with false teeth, iron deficiency anemia and dry mouth
Pronunciation
/kaɪˈlaɪtɪs/
Specialty
Dermatology
Symptoms
Redness, skin breakdown and crusting at the corner of the mouth[2]
Usual onset
Children, 30s to 60s[2]
Duration
Days to years[2]
Causes
Infection, irritation, allergies[2]
Treatment
Based on cause, barrier cream[2]
Frequency
0.7% of the population[3]
Angular cheilitis (AC) is inflammation of one or both corners of the mouth.[4][5] Often the corners are red with skin breakdown and crusting.[2] It can also be itchy or painful.[2] The condition can last for days to years.[2] Angular cheilitis is a type of cheilitis (inflammation of the lips).[6]
Angular cheilitis can be caused by infection, irritation, or allergies.[2] Infections include by fungi such as Candida albicans and bacteria such as Staph. aureus.[2] Irritants include poorly fitting dentures, licking the lips or drooling, mouth breathing resulting in a dry mouth, sun exposure, overclosure of the mouth, smoking, and minor trauma.[2] Allergies may include substances like toothpaste, makeup, and food.[2] Often a number of factors are involved.[2] Other factors may include poor nutrition or poor immune function.[2][5] Diagnosis may be helped by testing for infections and patch testing for allergies.[2]
Treatment for angular cheilitis is typically based on the underlying causes along with the use of a barrier cream.[2] Frequently an antifungal and antibacterial cream is also tried.[2] Angular cheilitis is a fairly common problem,[2] with estimates that it affects 0.7% of the population.[3] It occurs most often in the 30s to 60s, although is also relatively common in children.[2] In the developing world, iron and vitamin deficiencies are a common cause.[5]
Contents
1 Signs and symptoms
2 Causes
2.1 Infection
2.2 Irritation contact dermatitis
2.3 Nutritional deficiencies
2.4 Systemic disorders
2.5 Drugs
2.6 Allergic contact dermatitis
2.7 Loss of lower facial height
3 Diagnosis
3.1 Classification
4 Management
5 Prognosis
6 Epidemiology
7 Etymology
8 References
9 External links
Signs and symptoms[edit]
Angular cheilitis – a fissure running in the corner of the mouth with reddened, irritated facial skin adjacent.
A fairly mild case of angular cheilitis extending onto the facial skin in a young person (affected area is within the black oval).
Angular cheilitis is a fairly non specific term which describes the presence of an inflammatory lesion in a particular anatomic site (i.e. the corner of the mouth). As there are different possible causes and contributing factors from one person to the next, the appearance of the lesion is somewhat variable. The lesions are more commonly symmetrically present on both sides of the mouth,[4] but sometimes only one side may be affected. In some cases, the lesion may be confined to the mucosa of the lips, and in other cases the lesion may extend past the vermilion border (the edge where the lining on the lips becomes the skin on the face) onto the facial skin. Initially, the corners of the mouth develop a gray-white thickening and adjacent erythema (redness).[2] Later, the usual appearance is a roughly triangular area of erythema, edema (swelling) and breakdown of skin at either corner of the mouth.[2][4] The mucosa of the lip may become fissured (cracked), crusted, ulcerated or atrophied.[2][4] There is not usually any bleeding.[7] Where the skin is involved, there may be radiating rhagades (linear fissures) from the corner of the mouth. Infrequently, the dermatitis (which may resemble eczema) can extend from the corner of the mouth to the skin of the cheek or chin.[4] If Staphylococcus aureus is involved, the lesion may show golden yellow crusts.[8] In chronic angular cheilitis, there may be suppuration (pus formation), exfoliation (scaling) and formation of granulation tissue.[2][4]
Sometimes contributing factors can be readily seen, such as loss of lower face height from poorly made or worn dentures, which results in mandibular overclosure ("collapse of jaws").[9] If there is a nutritional deficiency underlying the condition, various other signs and symptoms such as glossitis (swollen tongue) may be present. In people with angular cheilitis who wear dentures, often there may be erythematous mucosa underneath the denture (normally the upper denture), an appearance consistent with denture-related stomatitis.[4] Typically the lesions give symptoms of soreness, pain, pruritus (itching) or burning or a raw feeling.[2][9]
Causes[edit]
Angular cheilitis is thought to be multifactorial disorder of infectious origin,[10] with many local and systemic predisposing factors.[11] The sores in angular cheilitis are often infected with fungi (yeasts), bacteria, or a combination thereof;[8] this may represent a secondary, opportunistic infection by these pathogens. Some studies have linked the initial onset of angular cheilitis with nutritional deficiencies, especially of the B(B2-riboflavin) vitamins and iron (which causes iron deficiency anemia),[12] which in turn may be evidence of malnutrition or malabsorption. Angular cheilitis can be a manifestation of contact dermatitis,[13] which is considered in two groups; irritational and allergic.
Infection[edit]
The involved organisms are:
Candida species alone (usually Candida albicans), which accounts for about 20% of cases,[14]
Bacterial species, either:
Staphylococcus aureus alone, which accounts for about 20% of cases,[14]
β-hemolytic streptococci alone. These types of bacteria have been detected in between 8–15% of cases of angular cheilitis,[2] but less commonly are they present in isolation,[10]
Or a combination of the above organisms, (a polymicrobial infection)[8] with about 60% of cases involving both C. albicans and S. aureus.[14][15]
Candida can be detected in 93% of angular cheilitis lesions.[2] This organism is found in the mouths of about 40% of healthy individuals, and it is considered by some to be normal commensal component of the oral microbiota.[2] However, Candida shows dimorphism, namely a yeast form which is thought to be relatively harmless and a pathogenic hyphal form which is associated with invasion of host tissues. Potassium hydroxide preparation is recommended by some to help distinguish between the harmless and the pathogenic forms, and thereby highlight which cases of angular cheilitis are truly caused by Candida.[2] The mouth may act as a reservoir of Candida that reinfects the sores at the corners of the mouth and prevents the sores from healing.
A lesion caused by recurrence of a latent herpes simplex infection can occur in the corner of the mouth. This is herpes labialis (a cold sore), and is sometimes termed "angular herpes simplex".[2] A cold sore at the corner of the mouth behaves similarly to elsewhere on the lips, and follows a pattern of vesicle (blister) formation followed by rupture leaving a crusted sore which resolves in about 7–10 days, and recurs in the same spot periodically, especially during periods of stress. Rather than utilizing antifungal creams, angular herpes simplex is treated in the same way as a cold sore, with topical antiviral drugs such as aciclovir.
Irritation contact dermatitis[edit]
A famous sketch by Leonardo da Vinci in preparation to depict the face of Judas Iscariot in The Last supper. The subject shows overclosure of the jaws and loss of facial support around the mouth.
Pronounced skin folds extending from the corner of the mouth.
Main article: Irritant contact dermatitis
22% of cases of angular cheilitis are due to irritants.[2] Saliva contains digestive enzymes, which may have a degree of digestive action on tissues if they are left in contact.[2] The corner of the mouth is normally exposed to saliva more than any other part of the lips. Reduced lower facial height (vertical dimension or facial support) is usually caused by edentulism (tooth loss), or wearing worn down, old dentures or ones which are not designed optimally. This results in overclosure of the mandible (collapse of the jaws),[9] which extenuates the angular skin folds at the corners of the mouth,[14] in effect creating an intertriginous skin crease. The tendency of saliva to pool in these areas is increased, constantly wetting the area,[10] which may cause tissue maceration and favors the development of a yeast infection.[14] As such, angular cheilitis is more commonly seen in edentulous people (people without any teeth).[9] It is by contrast uncommon in persons who retain their natural teeth.[16] Angular cheilitis is also commonly seen in denture wearers.[13] Angular cheilitis is present in about 30% of people with denture-related stomatitis.[10] It is thought that reduced vertical dimension of the lower face may be a contributing factor in up to 11% of elderly persons with angular cheilitis and in up to 18% of denture wearers who have angular cheilitis.[2] Reduced vertical dimension can also be caused by tooth migration, wearing orthodontic appliances, and elastic tissue damage caused by ultraviolet light exposure and smoking.[2]
Habits or conditions that keep the corners of the mouth moist might include chronic lip licking, thumb sucking (or sucking on other objects such as pens, pipes, lollipops), dental cleaning (e.g. flossing), chewing gum, hypersalivation, drooling and mouth breathing.[2][4][14] Some consider habitual lip licking or picking to be a form of nervous tic, and do not consider this to be true angular cheilitis,[4] instead calling it perlèche (derived from the French word pourlècher meaning "to lick one’s lips"),[2] or "factitious cheilitis" is applied to this habit.[2] The term "cheilocandidiasis" describes exfoliative (flaking) lesions of the lips and the skin around the lips, and is caused by a superficial candidal infection due to chronic lip licking.[14] Less severe cases occur during cold, dry weather, and is a form of chapped lips. Individuals may lick their lips in an attempt to provide a temporary moment of relief, only serving to worsen the condition.[17]
The sunscreen in some types of lip balm degrades over time into an irritant. Using expired lipbalm can initiate mild angular cheilitis, and when the person applies more lipbalm to alleviate the cracking, it only aggravates it. Because of the delayed onset of contact dermatitis and the recovery period lasting days to weeks, people typically do not make the connection between the causative agent and the symptoms.[medical citation needed]
Nutritional deficiencies[edit]
Several different nutritional deficiency states of vitamins or minerals have been linked to AC.[5] It is thought that in about 25% of people with AC, iron deficiency or deficiency of B vitamins are involved.[5] Nutritional deficiencies may be a more common cause of AC in Third World countries.[5] Chronic iron deficiency may also cause koilonychia (spoon shaped deformity of the fingernails) and glossitis (inflammation of the tongue). It is not completely understood how iron deficiency causes AC, but it is known that it causes a degree of immunocompromise (decreased efficiency of the immune system) which may in turn allow an opportunistic infection of candida.[5] Vitamin B2 deficiency (ariboflavinosis) may also cause AC, and other conditions such as redness of mucous membranes, magenta colored glossitis (pink inflammation of the tongue).[5] Vitamin B5 deficiency may also cause AC, along with glossitis, and skin changes similar to seborrhoeic dermatitis around the eyes, nose and mouth.[5] Vitamin B12 deficiency is sometimes responsible for AC, and commonly occurs together with folate deficiency (a lack of folic acid), which also causes glossitis and megaloblastic anemia.[5] Vitamin B3 deficiency (pellagra) is another possible cause, and in which other association conditions such as dermatitis, diarrhea, dementia and glossitis can occur.[5] Biotin (vitamin B7) deficiency has also been reported to cause AC, along with hair loss (alopecia) and dry eyes.[5] Zinc deficiency is known to cause AC.[18] Other symptoms may include diarrhea, alopecia and dermatitis.[5] Acrodermatitis enteropathica is an autosomal recessive genetic disorder causing impaired absorption of zinc, and is associated with AC.[5]
In general, these nutritional disorders may be caused by malnutrition, such as may occur in alcoholism or in poorly considered diets, or by malabsorption secondary to gastrointestinal disorders (e.g. Coeliac disease or chronic pancreatitis) or gastrointestinal surgeries (e.g. pernicious anemia caused by ileal resection in Crohn's disease).[5]
Systemic disorders[edit]
Some systemic disorders are involved in angular cheilitis by virtue of their association with malabsorption and the creation of nutritional deficiencies described above. Such examples include people with anorexia nervosa.[5] Other disorders may cause lip enlargement (e.g. orofacial granulomatosis),[5] which alters the local anatomy and extenuates the skin folds at the corners of the mouth. More still may be involved because they affect the immune system, allowing normally harmless organisms like Candida to become pathogenic and cause an infection. Xerostomia (dry mouth) is thought to account for about 5% of cases of AC.[5] Xerostomia itself has many possible causes, but commonly the cause may be side effects of medications, or conditions such as Sjögren's syndrome. Conversely, conditions which cause drooling or sialorrhoea (excessive salivation) can cause angular cheilitis by creating a constant wet environment in the corners of the mouth. About 25% of people with Down syndrome appear to have AC.[5] This is due to relative macroglossia, an apparently large tongue in a small mouth, which may constantly stick out of the mouth causing maceration of the corners of the mouth with saliva. Inflammatory bowel diseases (such as Crohn's disease or ulcerative colitis) can be associated with angular cheilitis.[4] In Crohn's, it is likely the result of malabsorption and immunosuppressive therapy which gives rise to the sores at the corner of the mouth.[9] Glucagonomas are rare pancreatic endocrine tumors which secrete glucagon, and cause a syndrome of dermatitis, glucose intolerance, weight loss and anemia. AC is a common feature of glucagonoma syndrome.[19] Infrequently, angular cheilitis may be one of the manifestations of chronic mucocutaneous candidiasis,[14] and sometimes cases of oropharyngeal or esophageal candidiasis may accompany angular cheilitis.[2] Angular cheilitis may be present in human immunodeficiency virus infection,[11] neutropenia,[16] or diabetes.[4] Angular cheilitis is more common in people with eczema because their skin is more sensitive to irritants.[2] Other conditions possibly associated include plasma cell gingivitis,[7] Melkersson-Rosenthal syndrome,[5] or sideropenic dysphagia (also called Plummer-Vinson syndrome or Paterson-Brown-Kelly syndrome).[5]
Drugs[edit]
Several drugs may cause AC as a side effect, by various mechanisms, such as creating drug-induced xerostomia. Various examples include isotretinoin, indinavir, and sorafenib.[5] Isotretinoin (Accutane), an analog of vitamin A, is a medication which dries the skin. Less commonly, angular cheilitis is associated with primary hypervitaminosis A,[20] which can occur when large amounts of liver (including cod liver oil and other fish oils) are regularly consumed or as a result from an excess intake of vitamin A in the form of vitamin supplements. Recreational drug users may develop AC. Examples include cocaine, methamphetamines, heroin, and hallucinogens.[5]
Allergic contact dermatitis[edit]
See also: Allergic contact cheilitis, Allergic contact dermatitis, and Allergic contact stomatitis
Patch test
Allergic reactions may account for about 25–34% of cases of generalized cheilitis (i.e., inflammation not confined to the angles of the mouth). It is unknown how frequently allergic reactions are responsible for cases of angular cheilitis, but any substance capable of causing generalized allergic cheilitis may present involving the corners of the mouth alone.
Examples of potential allergens include substances that may be present in some types of lipstick, toothpaste, acne products, cosmetics, chewing gum, mouthwash, foods, dental appliances, and materials from dentures or mercury containing amalgam fillings.[2] It is usually impossible to tell the difference between irritant contact dermatitis and allergic contact dermatitis without a patch test.
Loss of lower facial height[edit]
Severe tooth wear or ill fitting dentures may cause wrinkling at the corners of the lip that creates a favorable environment for the condition.[21] This can be corrected with onlays or crowns on the worn teeth to restore height or new dentures with "taller" teeth. The loss of vertical dimension has been associated with angular cheilitis in older individuals with an increase in facial laxity.[22]
Diagnosis[edit]
Photographic Comparison of: 1) a Canker Sore - inside the mouth, 2) Herpes, 3) Angular Cheilitis and 4) Chapped Lips.
Angular chielitis is normally a diagnosis made clinically. If the sore is unilateral, rather than bilateral, this suggests a local factor (e.g., trauma) or a split syphilitic papule.[4][23] Angular cheilitis caused by mandibular overclosure, drooling, and other irritants is usually bilateral.[2]
The lesions are normally swabbed to detect if Candida or pathogenic bacterial species may be present. Persons with angular cheilitis who wear dentures often also will have their denture swabbed in addition. A complete blood count (full blood count) may be indicated, including assessment of the levels of iron, ferritin, vitamin B12 (and possibly other B vitamins), and folate.[4]
Classification[edit]
Angular cheilitis could be considered to be a type of cheilitis or stomatitis. Where Candida species are involved, angular cheilitis is classed as a type of oral candidiasis, specifically a primary (group I) Candida-associated lesion.[11] This form angular cheilitis which is caused by Candida is sometimes termed "Candida-associated angular cheilitis",[11] or less commonly, "monilial perlèche".[2] Angular cheilitis can also be classified as acute (sudden, short-lived appearance of the condition) or chronic (lasts a long time or keeps returning), or refractory (the condition persists despite attempts to treat it).[2]
Management[edit]
There are 4 aspects to the treatment of angular cheilitis.[24] Firstly, potential reservoirs of infection inside the mouth are identified and treated.[24] Oral candidiasis, especially denture-related stomatitis is often found to be present where there is angular cheilitis, and if it is not treated, the sores at the corners of the mouth may often recur.[8][13] This involves having dentures properly fitted and disinfected. Commercial preparations are marketed for this purpose, although dentures may be left in dilute (1:10 concentration) household bleach overnight, but only if they are entirely plastic and do not contain any metal parts, and with rinsing under clean water before use.[9] Improved denture hygiene is often required thereafter, including not wearing the denture during sleep and cleaning it daily.[4] For more information, see Denture-related stomatitis.
Secondly, there may be a need to increase the vertical dimension of the lower face to prevent overclosure of the mouth and formation of deep skin folds.[24] This may require the construction of a new denture with an adjusted bite.[4] Rarely, in cases resistant to normal treatments, surgical procedures such as collagen injections (or other facial fillers such as autologous fat or crosslinked hyaluronic acid) are used in an attempt to restore the normal facial contour.[2][4] Other measures which seek to reverse the local factors that may be contributing to the condition include improving oral hygiene, stopping smoking or other tobacco habits and use of a barrier cream (e.g. zinc oxide paste) at night.[2]
Thirdly, treatment of the infection and inflammation of the lesions themselves is addressed. This is usually with topical antifungal medication,[8] such as clotrimazole,[14] amphotericin B,[24] ketoconazole,[16] or nystatin cream.[9] Some antifungal creams are combined with corticosteroids such as hydrocortisone[8] or triamcinolone[9] to reduce inflammation, and certain antifungals such as miconazole also have some antibacterial action.[8] Diiodohydroxyquinoline is another topical therapy for angular cheilitis.[14] If Staphylococcus aureus infection is demonstrated by microbiological culture to be responsible (or suspected), the treatment may be changed to fusidic acid cream,[8] an antibiotic which is effective against this type of bacteria. Aside from fusidic acid, neomycin,[24] mupirocin,[2] metronidazole,[7] and chlorhexidine[24] are alternative options in this scenario.
Finally, if the condition appears resistant to treatment, investigations for underlying causes such as anemia or nutrient deficiencies or HIV infection.[24] Identification of the underlying cause is essential for treating chronic cases. The lesions may resolve when the underlying disease is treated, e.g. with a course of oral iron or B vitamin supplements.[4] Patch testing is recommended by some in cases which are resistant to treatment and where allergic contact dermatitis is suspected.[2]
Prognosis[edit]
Most cases of angular cheilitis respond quickly when antifungal treatment is used.[16] In more long standing cases, the severity of the condition often follows a relapsing and remitting course over time.[14] The condition can be difficult to treat and can be prolonged.[4]
Epidemiology[edit]
AC is a relatively common condition,[11] accounting for between 0.7 – 3.8% of oral mucosal lesions in adults and between 0.2 – 15.1% in children, though overall it occurs most commonly in adults in the third to sixth decades of life.[2][4] It occurs worldwide, and both males and females are affected.[4] Angular cheilitis is the most common presentation of fungal and bacterial infections of the lips.[14]
Etymology[edit]
The term "angular cheilitis" is from Ancient greek, χείλος meaning lip and -itis meaning inflammation.
References[edit]
Jump up ^ Pindborg, Jens Jørgen (1973). Atlas of Diseases of the Oral Mucosa. Saunders. ISBN 9780721672649. Archived from the original on 10 September 2017. Retrieved 17 September 2014. Angular cheilosis: The lateral lip fissures, well known among denture wearers, have been called by a variety of names, such as "rhagades", "perleche", "angular cheilitis", and "angular cheilosis".
^ Jump up to: a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an ao ap aq ar as at au av aw ax ay az Park, KK; Brodell, RT; Helms, SE (June 2011). "Angular cheilitis, part 1: local etiologies". Cutis. 87 (6): 289–95. PMID 21838086.
^ Jump up to: a b Lyons, Faye (2014). Dermatology for the Advanced Practice Nurse. Springer Publishing Company. p. 95. ISBN 9780826136442. Archived from the original on 2016-08-16.
^ Jump up to: a b c d e f g h i j k l m n o p q r s t Scully, Crispian (2008). Oral and maxillofacial medicine : the basis of diagnosis and treatment (2nd ed.). Edinburgh: Churchill Livingstone. pp. 147–49. ISBN 9780443068188.
^ Jump up to: a b c d e f g h i j k l m n o p q r s t u v w Park, KK; Brodell RT; Helms SE. (July 2011). "Angular cheilitis, part 2: nutritional, systemic, and drug-related causes and treatment" (PDF). Cutis. 88 (1): 27–32. PMID 21877503. Archived from the original (PDF) on 2014-04-19.
Jump up ^ Martin, Elizabeth (2015). Concise Medical Dictionary. Oxford University Press. p. 136. ISBN 9780199687817. Archived from the original on 2016-08-16.
^ Jump up to: a b c Wood, NK; Goaz, PW (1997). Differential diagnosis of oral and maxillofacial lesions (5th ed.). St. Louis [u.a.]: Mosby. pp. 64–65, 85. ISBN 978-0815194323.
^ Jump up to: a b c d e f g h Coulthard P, Horner K, Sloan P, Theaker E (2008). Master dentistry volume 1, oral and maxillofacial surgery, radiology, pathology and oral medicine (2nd ed.). Edinburgh: Churchill Livingstone/Elsevier. pp. 180–81. ISBN 9780443068966.
^ Jump up to: a b c d e f g h Treister NS, Bruch JM (2010). Clinical oral medicine and pathology. New York: Humana Press. pp. 92–93, 144. ISBN 978-1-60327-519-4.
^ Jump up to: a b c d Soames JV, Southam JC, JV (1999). Oral pathology (3rd ed.). Oxford: Oxford Univ. Press. pp. 197–98. ISBN 0192628941.
^ Jump up to: a b c d e Tyldesley WR, Field A, Longman L (2003). Tyldesley's Oral medicine (5th ed.). Oxford: Oxford University Press. pp. 37, 40, 46, 63–67. ISBN 0192631470.
Jump up ^ MedlinePlus (2005-08-01). "Riboflavin (vitamin B2) deficiency (ariboflavinosis)". National Institutes of Health. Archived from the original on 2010-07-24.
^ Jump up to: a b c Peter C. Schalock, M.D.; Jeffrey T. S. Hsu, M.D.; Kenneth A. Arndt (eds.). Primary Care Dermatology. Lippincott Williams & Wilkins, 2010. p. 265. ISBN 978-0-7817-9378-0. Archived from the original on 2017-09-10.
^ Jump up to: a b c d e f g h i j k l Neville BW, Damm DD, Allen CA, Bouquot JE (2002). Oral & maxillofacial pathology (2nd ed.). Philadelphia: W.B. Saunders. pp. 100, 192, 196, 266. ISBN 0721690033.
Jump up ^ Kerawala C; Newlands C, eds. (2010). Oral and maxillofacial surgery. Oxford: Oxford University Press. p. 446. ISBN 9780199204830.
^ Jump up to: a b c d Greenberg MS, Glick M (2003). Burket's oral medicine diagnosis & treatment (10th ed.). Hamilton, Ont.: BC Decker. pp. 97–98, 550. ISBN 1550091867.
Jump up ^ Gibson, Lawrence E., M.D., "Dry Skin" Archived 2009-09-15 at the Wayback Machine., Mayo Clinic
Jump up ^ Gaveau D, Piette F, Cortot A, Dumur V, Bergoend H (1987). "[Cutaneous manifestations of zinc deficiency in ethylic cirrhosis]". Ann Dermatol Venereol. 114 (1): 39–53. PMID 3579131.
Jump up ^ Tadataka Yamada; David Alpers; Anthony Kalloo; Neil Kaplowitz; Chung Owyang; Don Powell, eds. (2009). Textbook of gastroenterology (5th ed.). Chichester, West Sussex: Blackwell Pub. pp. 1882–83. ISBN 978-1-4051-6911-0.
Jump up ^ Kliegman: Nelson Textbook of Pediatrics, 18th ed.
Jump up ^ Devani, Alim; Barankin, Benjamin (2007). "Answer: Can you identify this condition?". Canadian Family Physician. 53 (6): 1022–1023. ISSN 0008-350X. PMC 1949217  .
Jump up ^ "How Do I Manage a Patient with Angular Cheilitis? | jcda". www.jcda.ca. Retrieved 8 June 2018.
Jump up ^ Leyse-Wallace, Ruth (29 January 2013). Nutrition and Mental Health. CRC Press. p. 246. ISBN 9781439863350. Archived from the original on 10 September 2017. Retrieved 17 September 2014.
^ Jump up to: a b c d e f g Samaranayake, LP (2009). Essential microbiology for dentistry (3rd ed.). Elseveier. pp. 296–97. ISBN 978-0702041679.
External links[edit]
Classification
D
ICD-10: K13.0
ICD-9-CM: 528.5, 686.8
MeSH: D002613
Wikimedia Commons has media related to Angular cheilitis.
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Oral and maxillofacial pathology (K00–K06, K11–K14, 520–525, 527–529)
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Gigantiform
Cementoma
Eruption cyst
Epulis
Pyogenic granuloma
Congenital epulis
Gingival enlargement
Gingival cyst of the adult
Gingival cyst of the newborn
Gingivitis
Desquamative
Granulomatous
Plasma cell
Hereditary gingival fibromatosis
Hypercementosis
Hypocementosis
Linear gingival erythema
Necrotizing periodontal diseases
Acute necrotizing ulcerative gingivitis
Pericoronitis
Peri-implantitis
Periodontal abscess
Periodontal trauma
Periodontitis
Aggressive
As a manifestation of systemic disease
Chronic
Perio-endo lesion
Teething
show
Periapical, mandibular and maxillary hard tissues – Bones of jaws
Agnathia
Alveolar osteitis
Buccal exostosis
Cherubism
Idiopathic osteosclerosis
Mandibular fracture
Microgenia
Micrognathia
Intraosseous cysts
Odontogenic: periapical
Dentigerous
Buccal bifurcation
Lateral periodontal
Globulomaxillary
Calcifying odontogenic
Glandular odontogenic
Non-odontogenic: Nasopalatine duct
Median mandibular
Median palatal
Traumatic bone
Osteoma
Osteomyelitis
Osteonecrosis
Bisphosphonate-associated
Neuralgia-inducing cavitational osteonecrosis
Osteoradionecrosis
Osteoporotic bone marrow defect
Paget's disease of bone
Periapical abscess
Phoenix abscess
Periapical periodontitis
Stafne defect
Torus mandibularis
show
Temporomandibular joints, muscles of mastication and malocclusions – Jaw joints, chewing muscles and bite abnormalities
Bruxism
Condylar resorption
Mandibular dislocation
Malocclusion
Crossbite
Open bite
Overbite
Overeruption
Overjet
Prognathia
Retrognathia
Scissor bite
Maxillary hypoplasia
Temporomandibular joint dysfunction
show
Salivary glands
Benign lymphoepithelial lesion
Ectopic salivary gland tissue
Frey's syndrome
HIV salivary gland disease
Necrotizing sialometaplasia
Mucocele
Ranula
Pneumoparotitis
Salivary duct stricture
Salivary gland aplasia
Salivary gland atresia
Salivary gland diverticulum
Salivary gland fistula
Salivary gland hyperplasia
Salivary gland hypoplasia
Salivary gland neoplasms
Benign: Basal cell adenoma
Canalicular adenoma
Ductal papilloma
Monomorphic adenoma
Myoepithelioma
Oncocytoma
Papillary cystadenoma lymphomatosum
Pleomorphic adenoma
Sebaceous adenoma
Malignant: Acinic cell carcinoma
Adenocarcinoma
Adenoid cystic carcinoma
Carcinoma ex pleomorphic adenoma
Lymphoma
Mucoepidermoid carcinoma
Sclerosing polycystic adenosis
Sialadenitis
Parotitis
Chronic sclerosing sialadenitis
Sialectasis
Sialocele
Sialodochitis
Sialosis
Sialolithiasis
Sjögren's syndrome
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Orofacial soft tissues – Soft tissues around the mouth
Actinomycosis
Angioedema
Basal cell carcinoma
Cutaneous sinus of dental origin
Cystic hygroma
Gnathophyma
Ludwig's angina
Macrostomia
Melkersson–Rosenthal syndrome
Microstomia
Noma
Oral Crohn's disease
Orofacial granulomatosis
Perioral dermatitis
Pyostomatitis vegetans
show
Other
Eagle syndrome
Hemifacial hypertrophy
Facial hemiatrophy
Oral manifestations of systemic disease
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