Perioral dermatitis

Created 2009.

Learning objectives

Recognise and manage perioral dermatitis

Introduction

Perioral dermatitis is a common transient, recurrent or persistent rash affecting the muzzle area, hence its name. However, it often also affects skin adjacent to the eyes or nose, and sometimes around the anus or vagina, where it is more appropriately named “periorificial dermatitis”.

It appears more common in those with fair-skin and is particularly prevalent in women in their 20’s and 30’s.

Clinical features

Perioral and periorificial dermatitis are characterized by clusters of small papules and surrounding erythema. The surface may be scaly, and occasionally vesicles or tiny pustules develop. Typically, in contrast to contact dermatitis, 5-10mm skin adjacent to the vermilion of the lips is unaffected and may appear as a “white” ring. Symptoms vary from none to itch and burning discomfort depending on the severity and extent of the eruption.

Scaly papules

Papules and erythema

Papules and pustules

Papules on the glabella

Genital lesions

Unlike acne vulgaris, there are no comedones, cysts, or nodules. The areas affected are distinct from rosacea, which tends to occur a decade or so later and is accompanied by flushing and telangiectasia. However, longstanding perioral dermatitis is sometimes associated with telangiectasia, especially when due to topical steroids.

Perioral dermatitis may be precipitated by:

Topical steroids – especially potent products
Inhaled or intranasal topical steroids
Moisturisers – especially thick ones
Sunscreens and other cosmetics
Inadequate face-washing
Pregnancy or other hormonal change

The cause is unknown – theories include proliferation of commensal fusobacteria or Malassezia yeasts, and hypersensitivity reactions perhaps to sodium lauryl sulphate or an emollient ingredient.

The description “dermatitis” can be misleading – it is not an eczematous dermatitis. Topical steroids make it look better for a day or two, but result in more extensive and more inflamed papules. The most severe cases have always applied topical steroids for weeks or months, and flare severely when these are discontinued.

Treatment

Avoid oil-based facial creams -use water-based make-up and sunscreen.
Cleanse face twice daily with mild soap or non-soap non-cream cleanser and water
Oral anti-inflammatory antibiotics such as tetracycline 250-500 mg, doxycycline 100mg or minocycline 100mg daily for 4-8 weeks. Use erythromycin in pregnancy (if treatment is essential). A longer course may be required for longstanding cases with persistent erythema.
Topical agents are not very effective and in general are best avoided. However, erythromycin, metronidazole or azelaic acid preparations may be helpful in mild cases.
If a topical steroid has been applied, warn of a possible flare-up on stopping and if necessary continue a milder product at decreasing intervals over two or three weeks.