Perioral Dermatitis

Perioral dermatitis is a facial eruption of small red papules and pustules around the mouth, nose and sometimes the eyes, with a narrow clear rim around the lips. It is also called periorificial dermatitis.

It affects mainly women of 20 to 45 years, and occasionally children and men. It is common, and it is chronic and relapsing if triggers continue.

The strongest trigger is topical corticosteroid on the face, including inhaled and nasal steroids and face masks used with nebulisers. Other triggers include heavy emollients and cosmetics, fluorinated toothpaste, sunscreens, and oral contraceptives. A granulomatous form occurs in children and people with dark skin.

Pathophysiology.

The mechanism is unclear. Topical steroids alter the follicular and perioral skin barrier, promote microbial overgrowth (including Demodex and fusiform bacteria) and cause vasodilatation. Occlusion and moisture add to follicular irritation.

• Grouped 1 to 2 mm erythematous papules, papulovesicles and pustules around the mouth, in the nasolabial folds and on the chin, with sparing of a narrow rim next to the vermilion border.
• Periocular and perinasal extension in some patients.
• Burning, tightness and dryness more than itch, with scale.
• Flare after stopping a topical steroid, with temporary improvement when it is reapplied.

• Clinical diagnosis from the distribution, morphology and the history of topical steroid or occlusive product use.
• Bacterial swab and potassium hydroxide microscopy if pustules or scale are persistent.
• Skin biopsy only for atypical or granulomatous disease.
• Review of all facial and inhaled products.

Differential diagnosis. Rosacea, acne vulgaris, seborrhoeic dermatitis, allergic contact dermatitis, perioral impetigo, lip licking dermatitis, sarcoidosis, lupus and Demodex folliculitis.

• Stop all topical corticosteroids. After prolonged potent use, taper by changing to a milder steroid for 1 to 2 weeks to limit rebound, or stop abruptly if the patient accepts a flare.
• Stop cosmetics, heavy moisturisers and fluorinated toothpaste. Use only a mild non-foaming cleanser and a simple light emollient.
• Mild disease: topical metronidazole 0.75% gel or cream twice daily, erythromycin 2% twice daily, azelaic acid 15% gel twice daily, or pimecrolimus 1% cream twice daily, for 6 to 8 weeks.
• Moderate to severe or persistent disease: oral doxycycline 100 mg daily (or 40 mg modified release daily) or lymecycline 408 mg daily for 6 to 8 weeks, with topical treatment.
• Children under 12 years and pregnancy: oral erythromycin 30 to 50 mg/kg/day in 2 to 4 divided doses (adults 500 mg twice daily) for 6 to 8 weeks.
• Warn that the eruption often worsens for 2 to 3 weeks after stopping steroid, and that improvement takes weeks.
• Evidence for all treatments is weak.

Monitoring. Review at 4 to 6 weeks and again at 8 to 12 weeks. Recurrence is common if the trigger returns.

Referral and escalation. Refer to dermatology for resistant, granulomatous or atypical disease.

Special groups. Avoid tetracyclines in pregnancy and in children under 12 years. In children with a granulomatous form use topical or oral erythromycin.