PERIORAL DERMATITIS

By Gary M. White, MD

Perioral dermatitis induced by at topical steroid Topical steroid samples were the culprit here.


Perioral dermatitis (PD) is a common red, papular condition about the nose and mouth of young women. A common precipitating factor is a topical steroid. The steroid may have been started because of a mild facial eczema or lip cheilitis (either of which may have resolved) or it may have been given for the perioral dermatitis. Whatever the reason, the steroid is one reason the perioral dermatitis persists. It helps the rash some but never clears it and once the patient stops, the rash flares. One should inquire about the use of steroid-containing nasal sprays as beclomethasone dipropionate nasal spray for allergic rhinitis has been associated.

See also periorbital dermatitis and granulomatous periorificial dermatitis.

Clinical

The typical patient is a young adult woman who develops an itching and burning rash about the mouth. It often extends with confluent erythema along the mesolabial fold. The morphologic appearance is somewhere between an eczematous dermatitis and micropapular acne. Children may be affected as well. Weston and Morelli published a series of 106 children with perioral dermatitis. Most notably, 54% of children were using a class 7 steroid, including 1% hydrocortisone and over-the-counter products. Only 3% of children were using a class I (superpotent) steroid. The mean age was 7 years with a range of 6 months to 13 years. The perioral and perinasal areas were involved in almost every patient. Approximately 44% had involvement of the lower eyelids. Of note, there was a family history of rosacea in 20% of cases.

Treatment

It is important to stop all topical steroids. This may cause a flare, and the patient should be warned about this. Tapering down to hydrocortisone 1% cream for 1-2 weeks may be helpful in some. The most effective therapy is tetracycline 500 mg BID, doxycycline 100 mg BID, or minocycline 50-100 mg QD-BID for 1-2 months. Usually therapy is continued until the skin is clear and then another week or so. The patient should be told that recurrences may occur and the antibiotic may be taken again if needed. Usually, only one or two recurrences occur and after that, the skin stays clear. Topical erythromycin can help clear, but is not as fast as the oral tetracyclines. In resistant cases, consider local irritation (e.g., from tissue) or a contact dermatitis (e.g., cinnamic aldehyde in toothpaste).

Lower doses of the tetracyclines may be used, especially in patients who weigh less. For example doxycycline 20-50 mg po BID may be sufficient.

Topical pimecrolimus has been shown to speed healing of PD compared to vehicle in several controlled studies. Of note, topical tacrolimus has been reported to cause granulomatous rosacea.

Topical Praziquantel 3% ointment was significantly better than placebo in the treatment of perioral dermatitis [Clin Exp Dermatol 2014;39;448-453]. Praziquantel is an antiparasitic agent used to treat schistosomiasis, flat worms, and other parasites. Of note, it has also shown benefit as a topical agent for rosacea [Int J Dermatol. 2015 Apr;54(4):481-7.].

Oral isotretinoin may be considered in cases resistant to other forms of therapy.

See below for the use of ivermectin.

Children

For children under 9 years of age, tetracycline must be avoided. Treatment consists of abrupt cessation of any steroids, plus initiation of oral erythromycin. Complete clearing occurs in nearly all within 4-8 weeks. Alternatively, oral (single dose of 200-250 ug/kg) or topical (1%) ivermectin resulted in either complete or almost complete clearance in 14/15 children [JAAD 2017;76;567] with either periorificial dermatitis or papulopustular rosacea. The only side effect was mild desquamation in 5 patients. Of note, Soolantra is ivermectin 1%.

Topical clindamycin or metronidazole are other alternatives, but may be slower to clear the skin. See also granulomatous periorificial dermatitis.

Additional Pictures

Perioral dermatitis Perioral dermatitis

A more severe case induced by several months of triamcinolone--very similar to steroid rosacea.
Perioral dermatitis Perioral dermatitis

PD in a child.
Perioral dermatitis in a child

Multiple papules about the nostrils is not uncommon.
Perioral Dermatitis

Granulomatous periorificial dermatitis in a child.
Granulomatous periorificial dermatitis

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