What is the treatment for cracking around the lip?

Treatment of Cracking Around the Lip

Apply white soft paraffin ointment to the lips every 2 hours as the foundational treatment, combined with warm saline mouthwashes and benzydamine hydrochloride rinse for symptom control. 1, 2

Immediate First-Line Management

Core Treatment Protocol

• Apply white soft paraffin ointment every 2 hours to provide protection, maintain moisture, and prevent secondary infection 1, 2
• Perform warm saline mouthwashes 4 times daily (1 teaspoon salt, 1 teaspoon baking soda in 4 cups of water) to reduce bacterial load 1, 2
• Use benzydamine hydrochloride rinse or spray every 2-4 hours, particularly before eating, for pain relief 1, 2

Critical Product Avoidance

• Avoid petroleum-based products (petroleum jelly) as they cause drying and cracking of the lips 3
• Do not use alcohol-containing mouthwashes as they cause additional pain and irritation 1, 2

Note: While FDA labeling indicates petroleum jelly for chapped lips 4, the 2019 ASCO/MASCC guidelines specifically contradict this, recommending only animal or plant-based oils (beeswax, cocoa butter, lanolin) and explicitly warning against petroleum-based products due to drying effects 3. This guideline-level evidence takes precedence.

Treatment Based on Clinical Presentation

For Angular Cheilitis (Cracks at Lip Corners)

• Use combination antifungal-corticosteroid therapy as first-line treatment to address both Candida infection and inflammation simultaneously 2
• Antifungal options: nystatin oral suspension 100,000 units four times daily for 1 week OR miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 1, 2
• Corticosteroid component: betamethasone sodium phosphate 0.5 mg in 10 mL water as rinse-and-spit four times daily OR clobetasol propionate 0.05% mixed with Orabase applied directly to affected areas 2

For Inflammatory/Eczematous Cheilitis

• Apply topical corticosteroids (betamethasone or clobetasol) four times daily for initial inflammation control 1, 2
• For recalcitrant cases or when corticosteroid side effects are a concern, apply topical tacrolimus 0.1% ointment twice daily 2

For Suspected Secondary Infection

• Obtain bacterial and fungal cultures if purulent drainage, erythema, or warmth is present 1, 5
• If bacterial infection confirmed: use 0.2% chlorhexidine digluconate mouthwash twice daily for at least 14 days 1, 5
• If candidal involvement: prescribe nystatin oral suspension or miconazole oral gel 1, 5

Pain Management Algorithm

• Start with oral analgesics (paracetamol/acetaminophen) 20 minutes prior to eating 5
• If inadequate pain control: apply viscous lidocaine 2% topically 1, 2, 5
• For severe oral discomfort: consider cocaine mouthwashes 2-5% three times daily 2

Prevention Strategies

• Use alcohol-free moisturizing creams or ointments twice daily 1, 2
• Apply sunscreen SPF 15 on lips, reapplying every 2 hours when outside 1, 2
• Avoid frequent washing with hot water 1
• Avoid skin irritants including over-the-counter anti-acne medications, solvents, or disinfectants 1
• Maintain soft food intake with no biting/chewing in affected areas 5
• Avoid smoking, alcohol, and spicy foods 5

When to Reassess

• Reevaluate diagnosis if no improvement after 2 weeks of appropriate treatment 1, 2
• Consider underlying systemic conditions (diabetes, immunosuppression, nutritional deficiencies) in persistent cases 1, 2
• Immunocompromised patients require more aggressive and prolonged therapy 1, 2, 5
• Obtain urgent dermatology referral if fragile blisters, extensive erosions, or positive Nikolsky sign present (concern for pemphigus vulgaris) 5

Common Pitfalls

The most significant pitfall is using petroleum-based products, which despite widespread use and FDA approval for chapped lips, are specifically contraindicated by high-quality guideline evidence due to promoting mucosal dehydration and creating an occlusive environment that increases secondary infection risk 3, 2. Chronic alcohol-containing mouthwash use is another common error that worsens symptoms 1, 2.