Perioral Dermatitis

Perioral dermatitis is a rash that presents as bumps and pustules around the mouth. The cause of perioral dermatitis is unknown; however, the excessive use of topical steroids on the face often precedes the eruption of the perioral dermatitis.

Epidemiology:
The incidence is estimated to be 0.5-1% in industrialized countries. The incidence has decreased in the last ten years and this is likely to be due to greater awareness of the problems of prolonged use of topical steroids. Women aged 20-45 years are most commonly affected and account for an estimated 90% of the cases. The number of male cases is increasing and this is assumed to be because of changes in their use of cosmetics.

Etiology:
An underlying cause cannot be detected in all patients. Topical steroid preparations used excessively can cause the eruption to occur. No clear correlation exists between the risk of perioral dermatitis and the strength of the steroid or duration of use. Other causative factors include cosmetics, fluorinated toothpaste. Physical factors which worsen perioral dermatitis include UV light, heat, and wind. Candidiasis has been suggested as a provoking factor. Hormonal factors are suspected in women because of an observed premenstrual deterioration. Oral contraceptive use may also be a factor.

Presentation:

Redness, fine pink and red bumps and pustules around the mouth and cheeks. The pale area adjacent to the border of the mouth is characteristic. Occasionally, the eruption can be more widespread, when the eyelids and forehead are also affected. Sensation of burning and tension can occur, but itching is rare.

Management:
Patients require systemic and/or topical treatment, an evaluation of the underlying factors. Reassurance and education about possible underlying factors and the time course of the disease are necessary. The use of cosmetics, cleansers, and moisturizers should be avoided during treatment.

In mild cases, as well as in children and pregnant women, topical therapy is generally recommended. Metronidazole administered in a non-greasy gel can be prescribed. Ointments should be avoided. In severe forms, systemic treatment with anti-acne drugs is required. The drugs of choice are doxycycline (or tetracycline) and minocycline.

In unresponsive cases, oral isotretinoin may be considered. An initial worsening of the symptoms may occur with treatment, especially if topical steroids are withdrawn. The patient should be made aware of this complication. In cases of preceding long-term misuse of topical steroids, steroid weaning with low-dose 0.1-0.5% hydrocortisone cream can be tried initially.

Valerie Nozad, D.O.
Department of Dermatology
Philadelphia College of Osteopathic Medicine/Frankford Hospital
Philadelphia, Pennsylvannia.