What is the best course of treatment for an older adult with a dry and cracked lower lip, potentially caused by dehydration, nutritional deficiencies, or certain medications?

Treatment of Dry and Cracked Lower Lip in Older Adults

Apply white soft paraffin ointment every 2 hours during the acute phase to protect and moisturize the affected area, then transition to animal or plant-based oils (beeswax, cocoa butter, or lanolin) for daily maintenance once the skin barrier is restored. 1

Immediate Management (Acute Phase)

• Frequent application of white soft paraffin ointment every 2 hours provides immediate relief and prevents further moisture loss during the acute phase 1
• Continue this intensive regimen until the skin barrier is restored, typically several days to a week 1
• Lubricate lips with sterile vaseline/white paraffin (petrolatum), lip balm, or lip cream, but be aware that vaseline/white paraffin should not be used chronically on the lips as this promotes mucosal cell dehydration and is occlusive leading to risk of secondary infection 2

Addressing Underlying Causes

Hydration Assessment and Management

• Check serum or plasma osmolality to objectively assess hydration status, as simple clinical signs (skin turgor, mouth dryness, urine color) are unreliable in older adults 2
• If serum osmolality is >300 mOsm/kg, the patient has low-intake dehydration requiring increased fluid intake 2
• Offer a range of appropriate drinks according to patient preferences (water, tea, coffee, milk, fruit juices, soups) - plain water is not necessary for hydration 2
• Ensure adequate fluid intake of 2.0 L/day for women and 2.5 L/day for men from all sources (drinks and food) 2

Nutritional Considerations

• Ensure protein intake of at least 1.0 g/kg body weight daily, particularly in frail and multimorbid older persons 2
• Screen for malnutrition using the Mini Nutritional Assessment (MNA) short-form, as malnutrition commonly contributes to mucosal problems in older adults 2
• Maintain optimal nutritional support throughout treatment, as nutritional compromise can worsen oral tissue injury 2

Medication Review

• Review medications that may cause dry mouth (anticholinergics, diuretics, antihypertensives, antidepressants) and adjust if possible 3

When Infection is Present (Angular Cheilitis)

• Apply topical antifungal-corticosteroid combination if there is evidence of angular cheilitis with an infectious component to address both Candida infection and inflammation 1
• Alternative treatments include nystatin oral suspension or miconazole oral gel 1
• Use antiseptic oral rinse containing 0.2% chlorhexidine twice daily if bacterial component is suspected 1

Supportive Oral Care Measures

• Clean the area daily with warm saline mouthwashes 1
• Apply benzydamine hydrochloride rinse or spray every 3 hours if the area is painful 1
• Inspect oral mucosa daily for changes 2
• Use a soft toothbrush after meals and before sleep with mild fluoride-containing, non-foaming toothpaste 2
• Ensure proper use of dentures and eliminate sources of mechanical trauma (ill-fitting prostheses, fractured teeth) 2, 1

Critical Pitfalls to Avoid

• Do NOT use alcohol-containing mouthwashes, which cause additional pain and irritation 1
• Do NOT use glycerin or lemon-glycerin swabs, which dry the mouth rather than moisturize 1
• Do NOT use petroleum-based products chronically beyond the initial healing phase, as they promote mucosal cell dehydration and risk of secondary infection 2, 1
• Do NOT rely on clinical signs alone (skin turgor, mouth dryness) to assess hydration status in older adults - these are unreliable 2

Long-Term Maintenance After Healing

• Transition to animal or plant-based lip moisturizers such as beeswax, cocoa butter, or lanolin for daily maintenance 1
• Apply bland lip balm with ultraviolet protection regularly 4
• Address any mechanical factors like ill-fitting dentures or loss of vertical dimension 1
• Maintain good oral hygiene with gentle brushing and bland rinses 1
• Protect lips from harsh weather conditions 4
• Ensure adequate ongoing hydration with regular fluid intake throughout the day 3

When to Escalate Care

• If the condition does not improve within 1-2 weeks of appropriate treatment, consider referral to dermatology or oral medicine 3
• Persistent or recurrent lesions may require biopsy to rule out actinic cheilitis or other pathology 5
• Severe cases with significant inflammation may require specialty consultation 3