The lipstick sign is an underutilized physical examination finding which can assist in the evaluation and assessment of the elderly female patient. While poorly applied lipstick can result in considerable embarrassment and anxiety in this patient population, those who present with properly applied lipstick demonstrate mastery of multiple domains of functioning.
Fine motor skills and concentration can be correlated with a positive lipstick sign. Hydration status can also be inferred by lack of feathering or cracking of the lips. Translocation of lipstick to the central incisors has been associated with Sjögren’s syndrome. Furthermore, subtle neurologic abnormalities such as facial droop or dysarthria may be more easily identified in affected patients when the lipstick sign is present. A substantial minority of elderly females living in the community and in nursing homes apply lipstick daily with variation in quality, control and frequency of application. The majority of persons presenting with a positive lipstick sign are not assessed in this cosmetologic domain.
The lipstick sign is associated with increased social and family support, positive self-image, and decreased likelihood of depression. Interestingly, the lipstick sign has been associated with a decrease risk of fall and hip fracture, although studies have been limited in size and are funded primarily by the cosmetic industry. Inherently, the lipstick sign is most useful within 6 hours of application, with physical examination findings decreasing in a brand-dependent fashion. Further complicating interpretation, the oral intake patterns of the patient can limit the use of the lipstick sign although careful evaluation of glassware can serve as a surrogate marker.
Proper lipstick application relies on appropriate function of gross motor, fine motor, visual acuity and visuospatial skills. Relevant anatomy of the lipstick sign examination includes delineation of the vermillion border, philtrum, oral commissure and in unfortunate cases, the incisors. Abnormalities in any of these anatomic features requires more nuanced understanding of the functional foundation of the lipstick sign.
While formally a part of the physical examination, the lipstick sign can contribute significantly to the social history and often can further discussion of the activities of daily living which the patient can perform. Patients may be particularly anxious about their physical appearance at the time of presentation. In order to avoid embarrassment, acknowledgement of poor or haphazard application should be avoided. However, depending on the social milieu, it would be appropriate to notify the patient of lipstick present in an unexpected location such as the central incisors.
The lipstick sign has been dismissed by some as inaccurate for assessing functional and cognitive status. As with any physical examination finding, it must be interpreted in context and serves only to support an overall presentation or assessment. When performed by a knowledgeable examiner, recognition of the
lipstick sign can efficiently contribute to global assessment of an elderly female’s functional status. Closely correlated to this sign are the nail polish sign, the white sneaker sign and the presence of an advanced digital device (ADD) at the bedside.
Elizabeth Horn is a resident physician.
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