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This article written by Nikki Levin, MD, PhD
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Introduction: What is perioral dermatitis?
Figure 1. A woman who has used strong corticosteroid creams on her face developed the characteristic tiny, uniform scaly bumps of perioral dermatitis around her mouth and nose.
What causes perioral dermatitis?
The major cause of perioral dermatitis is use of strong corticosteroid medications on the face. Corticosteroids are anti-inflammatory drugs, often used for skin conditions such as eczema, psoriasis, or poison ivy. They range in strength from over--the--counter hydrocortisone 1% cream, which is relatively safe to use anywhere on the body, to very potent prescription medications such as fluocinonide and clobetasol, which are not meant to be used on the face or other delicate areas such as the underarms, groin, breasts, or buttocks.
When individuals who have some type of minor skin irritation on the face treat their facial skin with strong corticosteroid creams, they may find that the skin condition initially improves. However, when they stop using the corticosteroid cream, their rash may worsen again, with the appearance of small scaly bumps around the mouth, nose, or eyes. This causes them to use the corticosteroid over and over until their skin becomes “addicted” to it. Any attempt to stop using the cream results in an even worse rash than they had initially. Perioral dermatitis has even developed in patients who use inhaled corticosteroids for asthma or hay fever, if they allow the medication to drip onto their skin.
Other potential causes of perioral dermatitis include toothpaste ingredients such as whitening or tartar control agents. It is thought that transfer of saliva to the skin around the mouth may play a role in perioral dermatitis, since it is more common in young children and oral surgery patients, both of whom tend to leak saliva onto their skin, i.e., drool.
Some studies have shown that excessive use of foundation makeup, moisturizers and night creams is associated with perioral dermatitis.
Other studies suggest that perioral dermatitis is more common in people who have atopic dermatitis, a form of eczema. It is not clear whether having atopic dermatitis makes people more likely to get perioral dermatitis or whether it makes them more likely to have strong topical corticosteroids which they can use on their face, leading to perioral dermatitis.
Researchers have attempted to link perioral dermatitis to infectious organisms such as Candida yeasts, Demodex mites, and fusiform bacteria, but no conclusive role for these organisms has been demonstrated.
Who gets perioral dermatitis?
Perioral dermatitis is predominantly a disease of children and young women. Both boys and girls may get perioral dermatitis, but it is very uncommon in adult men. There does not seem to be any difference in rates of perioral dermatitis between different racial or ethnic groups.
What are the symptoms of perioral dermatitis?
Perioral dermatitis may be mildly itchy, sore, or cause no symptoms at all. Individuals who have perioral dermatitis are most often bothered by the appearance more than any discomfort from the rash.
What does perioral dermatitis look like?
As its name suggests, perioral dermatitis is a rash that occurs around the mouth, especially at the corners of the mouth (Figure 2). The area of skin directly adjacent to the lips, however, is usually unaffected. Other areas that are commonly involved are the chin, the skin around the nostrils (Figure 3), and around the eyes (Figure 4). In one study of children with perioral dermatitis, 26% had no rash around the mouth at all.
The rash characteristically appears as tiny (1-2 mm) uniform bumps that are flesh colored or pink. The bumps are often scaly (flaky) and may have a tiny white pustule on their surface. In children, the bumps may even be yellowish or dark-colored. The rash may range in severity from just a few subtle bumps (Figure 5) to widespread involvement of the entire “muzzle” area (Figure 1).
Figure 2. Perioral dermatitis often appears at the corners of the mouth and on the chin and may be asymmetrical, affecting only one side of the face.
Figure 3. This woman has tiny uniform bumps around her nostrils and mouth.
Figure 4. This boy developed perioral dermatitis only around his eyes.
Figure 5. This woman developed a few bumps on her chin after using a new toothpaste.
What conditions does perioral dermatitis resemble?
There are several skin diseases that have similarities to perioral dermatitis, but they can be distinguished from perioral dermatitis by the following differences:
- Acne: unlike perioral dermatitis, several types of lesion in addition to small bumps are usually seen, including blackheads, whiteheads, pus bumps, nodules, and cysts.
- Rosacea: this skin condition may have small bumps on the face, but in addition, has facial redness, dilated blood vessels, and a tendency toward flushing.
- Seborrheic dermatitis: this skin condition has scaling around the nose, in the scalp and on the eyebrows, rather than bumps on the skin.
- Lip–licker’s dermatitis: this condition, which results from excessive lip-licking, looks like dry, peeling, or crusty skin around the mouth, but without bumps.
- Contact dermatitis: this condition, which results from irritation or allergy to foods or facial products, looks like a red, scaly, crusted rash around the mouth, without bumps.
How is perioral dermatitis diagnosed?
Perioral dermatitis has a very characteristic appearance that usually makes the diagnosis straightforward. In cases where the diagnosis is unclear, however, a biopsy can be performed. Although perioral dermatitis does not have a characteristic microscopic appearance, a biopsy can be useful to rule out other diseases with which it might be confused (see above). If contact dermatitis is suspected, sometimes patch testing can be useful to determine a cause.
How can one prevent and treat perioral dermatitis?
The most important measure in prevention and treatment of perioral dermatitis is avoidance of strong topical corticosteroid creams on the face. Because the rash tends to flare when one stops using strong steroid creams, doctors will sometimes substitute a weaker steroid cream during the healing phase. Recent studies have shown that pimecrolimus, a topical medication that is FDA-approved for atopic dermatitis, may also be a useful substitute for corticosteroids during the healing phase of perioral dermatitis. It is important not to restart strong steroids on the face, even if the rash flares.
In cases where toothpastes, makeups, or moisturizers are thought to play a role in perioral dermatitis, it is advisable to try discontinuing them or switching brands.
In addition to recommending the preventive measures above, doctors treat perioral dermatitis with a number of oral and topical medicines. Most of the medicines that are effective for perioral dermatitis are antibiotics, despite the fact that this disease is not thought to be caused by bacteria. It is believed that the antibiotics may have an anti-inflammatory effect on the skin in addition to their antibiotic properties. The choice of antibiotics is based on the age of the patient and the severity of their perioral dermatitis. Antibiotics are generally used for 1-2 months or until the rash resolves.
The following are commonly used medications for perioral dermatitis:
- Oral antibiotics: tetracycline, doxycycline, minocycline, erythromycin
- Topical antibiotics: clindamycin, erythromycin, metronidazole
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How long does perioral dermatitis take to get better?
If it is not treated, perioral dermatitis may last for months, especially if corticosteroid creams are still being used on the face. With treatment, the rash usually clears within 6-8 weeks. Although perioral dermatitis may occasionally recur, it usually responds well to re-treatment.
Is perioral dermatitis a serious illness?
Although perioral dermatitis does not cause death or disability and usually does not scar, it is still important to diagnose and treat. Individuals with perioral dermatitis may be very uncomfortable with itching or burning of their skin and they are often distressed by the appearance of the rash. More importantly, the development of perioral dermatitis is a sign that someone may have been using strong corticosteroids on the face. Prolonged use of steroids on the face may cause permanent skin damage, including thinning of the skin, stretch marks, and dilated blood vessels. It is, therefore, important to identify people who are using corticosteroids in this way and educate them on the proper use of these powerful medications.
Book Chapters about Perioral dermatitis
Habif TP. Acne, rosacea, and related disorders, pp. 180-181, in Clinical Dermatology, Third edition. Mosby, St. Louis, 1996.
Chamlin SL and Lawley LP. Chapter 80. Perioral dermatitis, pp 709-712 in Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS and Leffell DJ, eds. Fitzpatrick’s Dermatology in General Medicine, Seventh Edition, Volume 1. McGraw Hill Medical, New York, 2008.
Boeck K, Abeck D, Werfel S, Ring J. Perioral dermatitis in children—clinical presentation, pathogenesis-related factors and response to topical metronidazole. Dermatology 1997; 195(3): 235-238.
Choi YL, Lee KJ, Cho HJ, Kim WS, Lee JH, Yang JM, Lee ES, Lee DY. Case of childhood granulomatous periorificial dermatitis in a Korean boy treated by oral erythromycin. J Dermatol. 2006; 33:806-808.
Hafeez ZH. Perioral dermatitis: an update. Int J Dermatol. 2003; 42:514-517.
Hussain W, Daly BM. Granulomatous periorificial dermatitis in an 11-year old boy: dramatic response to tacrolimus. J Eur Acad Dermatol Venereol. 2007; 21:1137-139.
Knautz MA, Lesher JL. Childhood granulomatous periorificial dermatitis. Pediatr Dermatol. 1996; 13:131-134.
Nguyen V, Eichenfield LF. Periorificial dermatitis in children and adolescents. J Amer Acad Dermatol. Nov 2006; 55(5):781-785.
Oppel T, Pavicic T, Kamann S, Brautigam M, Wollenberg A. Pimecrolimus cream (1%) efficacy in perioral dermatitis - results of a randomized, double-blind, vehicle-controlled study in 40 patients. J Eur Acad Dermatol Venereol. Oct 2007; 21(9):1175-80.
Sneddon I. Perioral dermatitis. Br J Derm. 1972; 87:430-434.
Weber K, Thurmayr R. Critical appraisal of reports on the treatment of perioral dermatitis. Dermatology. 2005; 210:300-307.
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