Management of acute pseudomembranous candidiasis with angular cheilitis in diabetic patient
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Jun 26, 2025
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Abstract
Diabetes mellitus (DM) is being increasingly documented even in developing countries. C. albicans infection is frequently found in diabetic patients. Diabetics and the ‘poorly controlled patients are considered as immunocompromised, though it is not easy to characterise the immunologic deficiencies clearly. Since infection is mostly preceded by colonization. The risk factors that increased the risk of Candida carriage in diabetic patients with DM were a higher age and a higher HbA1c level (poor regulation of DM). The purpose of this study is to report the management of Acute Pseudomembranous Candidiasis with Angular Cheilitis in diabetic patients. A 51-year-old lady complained of dryness and pain in the corner of the mouth, recurrence within 2 years after she had been diagnosed diabetic, which had worsened in the last two weeks. The corner of the mouth showed a fissure with reddish area. Oral mucosa showed multiple yellow-white pseudomembranous. The patient was prescribed antiseptic mouthwash and an antifungal oral suspension, which should be applied to the lesion 3-4 times daily. Ketoconazole, as a systemic antifungal, was given 200 mg/day. The laboratory test showed an increase in leucocytes cells count, monocytes, and ESR. A direct mycological examination and culture observation Candida albicans was performed. Referral to an internist to manage her systemic condition. This study concludes that immune dysfunctions in diabetics is contribute to the pathogenesis of Oral Candidiasis and Angular Cheilitis, which may lead to optimum treatment.
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How to Cite
Winias, S., Hadi, P., Prasetya, S. G. and Sinaga, A. J. Y. (2025) “Management of acute pseudomembranous candidiasis with angular cheilitis in diabetic patient”, Science Midwifery, 13(2), pp. 596-604. doi: 10.35335/midwifery.v13i2.1980.
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Akpan & Morgan. (2002). Oral Candidiasis. Postgraduate Medical Journal, 78(922), 455–459. https://doi.org/10.1136/pmj.78.922.455
Al Maweri, S. A. A., Ismail, N. M., Ismail, A. R., & Al-Ghashm, A. (2013). Prevalence of oral mucosal lesions in patients with type 2 diabetes attending hospital Universiti Sains Malaysia. Malaysian Journal of Medical Sciences, 20(4), 38–45.
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de Souza Bastos, A., Leite, A. R. P., Spin-Neto, R., Nassar, P. O., Massucato, E. M. S., & Orrico, S. R. P. (2011). Diabetes mellitus and oral mucosa alterations: Prevalence and risk factors. Diabetes Research and Clinical Practice, 92(1), 100–105. https://doi.org/10.1016/j.diabres.2011.01.011
Deepa, A. G., Nair, B. J., Sivakumar, T. T., & Joseph, A. P. (2014). Uncommon opportunistic fungal infections of oral cavity : A review. 18(2), 235–244. https://doi.org/10.4103/0973-029X.140765
Dongari-bagtzoglou, A. (2005). Innate Defense Mechanism in Oral Candidiasis. In Fungal Immunology (pp. 14–34).
Fajriani, F. (2017). Management of Angular Cheilitis in children. Journal of Dentomaxillofacial Science, 2(1), 1. https://doi.org/10.15562/jdmfs.v2i1.461
Field, E. A., Longman, L., & Tyldesley, W. R. (2003). Tyldesley’s Oral medicine. In Oxford medical publications (pp. xi, 243 p.).
Geerlings, S. E., & Hoepelman, A. I. (1999). Immune dysfunction in patients with diabetes mellitus (DM). FEMS Immunolo Med Microbiol, 26, 259–265. https://doi.org/10.1111/j.1574-695X.1999.tb01397.x
Ghom, et al. (2014). Text book of Oral Medicine (3rd ed.). JaypeeBrothers Medical Publishers.
Glick, M., & Feagan Chair, W. (2015). Burket’s Oral Medicine. In People’s Medical Publishing House. https://doi.org/10.1007/s13398-014-0173-7.2
Hashim, I., & Mascellino, M. T. (2014). Bacterial and Mycotic Infections in Immunocompromised Hosts : Clinical and Microbiological Aspects.
Hidalgo, S. F., De Paula, J. M. P., & Valdivieso, I. S. (2010). Metformina y deficiencia de vitamina B12. Medicina Clinica, 135(6), 286–287. https://doi.org/10.1016/j.medcli.2009.04.055
Lecube, A., Pachón, G., Petriz, J., Hernández, C., & Simó, R. (2011). Phagocytic activity is impaired in type 2 diabetes mellitus and increases after metabolic improvement. PLoS ONE, 6(8), 6–11. https://doi.org/10.1371/journal.pone.0023366
Marsh, P. D., & Martin, M. V. (2009). Oral Microbiology. In Churchill Livingstone Elsevier-UK.
Martinez, R. F. F., Hernández-Pérez, F., Miguel, G. F. S., Jaimes-Aveldañez, A., & Arenas, R. (2013). Portadores de Candida spp na cavidade oral: A sua prevalência em pacientes com diabetes Mellitus tipo 2. Anais Brasileiros de Dermatologia, 88(2), 222–225. https://doi.org/10.1590/S0365-05962013000200006
Patil, S., Rao, R. S., Majumdar, B., & Anil, S. (2015). Clinical appearance of oral Candida infection and therapeutic strategies. Frontiers in Microbiology, 6(DEC), 1–10. https://doi.org/10.3389/fmicb.2015.01391
Peters, B. M., Ovchinnikova, E. S., Krom, B. P., Schlecht, L. M., Zhou, H., Hoyer, L. L., Busscher, H. J., van der Mei, H. C., Jabra-Rizk, M. A., & Shirtliff, M. E. (2012). Staphylococcus aureus adherence to Candida albicans hyphae is mediated by the hyphal adhesin Als3p. Microbiology (United Kingdom), 158(12), 2975–2986. https://doi.org/10.1099/mic.0.062109-0
Ryalat, S., Darwish, R., & Amin, W. (2011). New form of administering chlorhexidine for treatment of denture-induced stomatitis. Therapeutics and Clinical Risk Management, 7, 219–225. https://doi.org/10.2147/TCRM.S18297
Sashikumar, R., & Kannan, R. (2010). Salivary glucose levels and oral candidal carriage in type II diabetics. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, 109(5), 706–711. https://doi.org/10.1016/j.tripleo.2009.12.042
Scully, C. (2013). Oral and Maxillofacial Medicine The Basis of Diagnosis And Treatment (3rd ed.). Elseiver Ltd.
Shahzad, M., Faraz, R., & Sattar, A. (2014). Angular Cheilitis : Case Reports and Literature Review. 34(4), 597–599.
Tucker, R. (2010). Angular cheilitis. Pharmaceutical Journal, 285(7621), 374.
Williams, D., & Lewis, M. (2011). Pathogenesis and treatment of oral candidosis. Journal of Oral Microbiology, 3(2011), 1–11. https://doi.org/10.3402/jom.v3i0.5771
Yapar, N. (2014). Epidemiology and risk factors for invasive candidiasis. Therapeutics and Clinical Risk Management, 10(1), 95–105. https://doi.org/10.2147/TCRM.S40160
Aitken-Saavedra, J., Rojas-Alcayaga, G., Maturana-Ramirez, A., Escobar-Alvarez, A., Cortes-Coloma, A., Reyes-Rojas, M., Viera -Sapiain, V., Villablanca-Martinez, C., & Morales-Bozo, I. (2015). Salivary gland dysfunction markers in type 2 diabetes mellitus patients. Journal of Clinical and Experimental Dentistry, 7(4), e501–e505. https://doi.org/10.4317/jced.52329
Akpan & Morgan. (2002). Oral Candidiasis. Postgraduate Medical Journal, 78(922), 455–459. https://doi.org/10.1136/pmj.78.922.455
Al Maweri, S. A. A., Ismail, N. M., Ismail, A. R., & Al-Ghashm, A. (2013). Prevalence of oral mucosal lesions in patients with type 2 diabetes attending hospital Universiti Sains Malaysia. Malaysian Journal of Medical Sciences, 20(4), 38–45.
Aroda, V. R., Edelstein, S. L., Goldberg, R. B., Knowler, W. C., Marcovina, S. M., Orchard, T. J., Bray, G. A., Schade, D. S., Temprosa, M. G., White, N. H., & Crandall, J. P. (2016). Long-term Metformin Use and Vitamin B12 Deficiency in the Diabetes Prevention Program Outcomes Study. The Journal of Clinical Endocrinology & Metabolism, 101(4), 1754–1761. https://doi.org/10.1210/jc.2015-3754
Balan, P., Castelino, R. L., & Fazil Areekat, B. K. (2015). Candida Carriage Rate and Growth Characteristics of Saliva in Diabetes Mellitus Patients: A Case‒Control Study. J Dent Res Dent Clin Dent Prospect, 9(4), 274–279. https://doi.org/10.15171/joddd.2015.048
Belazi, M., Velegraki, A., Fleva, A., Gidarakou, I., Papanaum, L., Baka, D., Daniilidou, N., & Karamitsos, D. (2005). Candidal overgrowth in diabetic patients: Potential predisposing factors. Mycoses, 48(3), 192–196. https://doi.org/10.1111/j.1439-0507.2005.01124.x
Bremenkamp, R. M., Caris, A. R., Jorge, A. O. C., Back-brito, G. N., Mota, A. J., Balducci, I., Brighenti, F. L., & Koga-ito, C. Y. (2011). Prevalence and antifungal resistance profile of Candida spp . oral isolates from patients with type 1 and 2 diabetes mellitus. Archives of Oral Biology, 56(6), 549–555. https://doi.org/10.1016/j.archoralbio.2010.11.018
Cheung, H. Y., Wong, M. M. K., Cheung, S. H., Liang, L. Y., Lam, Y. W., & Chiu, S. K. (2012). Differential actions of chlorhexidine on the cell wall of bacillus subtilis and escherichia coli. PLoS ONE, 7(5). https://doi.org/10.1371/journal.pone.0036659
de Souza Bastos, A., Leite, A. R. P., Spin-Neto, R., Nassar, P. O., Massucato, E. M. S., & Orrico, S. R. P. (2011). Diabetes mellitus and oral mucosa alterations: Prevalence and risk factors. Diabetes Research and Clinical Practice, 92(1), 100–105. https://doi.org/10.1016/j.diabres.2011.01.011
Deepa, A. G., Nair, B. J., Sivakumar, T. T., & Joseph, A. P. (2014). Uncommon opportunistic fungal infections of oral cavity : A review. 18(2), 235–244. https://doi.org/10.4103/0973-029X.140765
Dongari-bagtzoglou, A. (2005). Innate Defense Mechanism in Oral Candidiasis. In Fungal Immunology (pp. 14–34).
Fajriani, F. (2017). Management of Angular Cheilitis in children. Journal of Dentomaxillofacial Science, 2(1), 1. https://doi.org/10.15562/jdmfs.v2i1.461
Field, E. A., Longman, L., & Tyldesley, W. R. (2003). Tyldesley’s Oral medicine. In Oxford medical publications (pp. xi, 243 p.).
Geerlings, S. E., & Hoepelman, A. I. (1999). Immune dysfunction in patients with diabetes mellitus (DM). FEMS Immunolo Med Microbiol, 26, 259–265. https://doi.org/10.1111/j.1574-695X.1999.tb01397.x
Ghom, et al. (2014). Text book of Oral Medicine (3rd ed.). JaypeeBrothers Medical Publishers.
Glick, M., & Feagan Chair, W. (2015). Burket’s Oral Medicine. In People’s Medical Publishing House. https://doi.org/10.1007/s13398-014-0173-7.2
Hashim, I., & Mascellino, M. T. (2014). Bacterial and Mycotic Infections in Immunocompromised Hosts : Clinical and Microbiological Aspects.
Hidalgo, S. F., De Paula, J. M. P., & Valdivieso, I. S. (2010). Metformina y deficiencia de vitamina B12. Medicina Clinica, 135(6), 286–287. https://doi.org/10.1016/j.medcli.2009.04.055
Lecube, A., Pachón, G., Petriz, J., Hernández, C., & Simó, R. (2011). Phagocytic activity is impaired in type 2 diabetes mellitus and increases after metabolic improvement. PLoS ONE, 6(8), 6–11. https://doi.org/10.1371/journal.pone.0023366
Marsh, P. D., & Martin, M. V. (2009). Oral Microbiology. In Churchill Livingstone Elsevier-UK.
Martinez, R. F. F., Hernández-Pérez, F., Miguel, G. F. S., Jaimes-Aveldañez, A., & Arenas, R. (2013). Portadores de Candida spp na cavidade oral: A sua prevalência em pacientes com diabetes Mellitus tipo 2. Anais Brasileiros de Dermatologia, 88(2), 222–225. https://doi.org/10.1590/S0365-05962013000200006
Patil, S., Rao, R. S., Majumdar, B., & Anil, S. (2015). Clinical appearance of oral Candida infection and therapeutic strategies. Frontiers in Microbiology, 6(DEC), 1–10. https://doi.org/10.3389/fmicb.2015.01391
Peters, B. M., Ovchinnikova, E. S., Krom, B. P., Schlecht, L. M., Zhou, H., Hoyer, L. L., Busscher, H. J., van der Mei, H. C., Jabra-Rizk, M. A., & Shirtliff, M. E. (2012). Staphylococcus aureus adherence to Candida albicans hyphae is mediated by the hyphal adhesin Als3p. Microbiology (United Kingdom), 158(12), 2975–2986. https://doi.org/10.1099/mic.0.062109-0
Ryalat, S., Darwish, R., & Amin, W. (2011). New form of administering chlorhexidine for treatment of denture-induced stomatitis. Therapeutics and Clinical Risk Management, 7, 219–225. https://doi.org/10.2147/TCRM.S18297
Sashikumar, R., & Kannan, R. (2010). Salivary glucose levels and oral candidal carriage in type II diabetics. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, 109(5), 706–711. https://doi.org/10.1016/j.tripleo.2009.12.042
Scully, C. (2013). Oral and Maxillofacial Medicine The Basis of Diagnosis And Treatment (3rd ed.). Elseiver Ltd.
Shahzad, M., Faraz, R., & Sattar, A. (2014). Angular Cheilitis : Case Reports and Literature Review. 34(4), 597–599.
Tucker, R. (2010). Angular cheilitis. Pharmaceutical Journal, 285(7621), 374.
Williams, D., & Lewis, M. (2011). Pathogenesis and treatment of oral candidosis. Journal of Oral Microbiology, 3(2011), 1–11. https://doi.org/10.3402/jom.v3i0.5771
Yapar, N. (2014). Epidemiology and risk factors for invasive candidiasis. Therapeutics and Clinical Risk Management, 10(1), 95–105. https://doi.org/10.2147/TCRM.S40160