Periorificial Dermatitis (perioral dermatitis)

Are You Confident of the Diagnosis?

Periorificial dermatitis, also referred to as perioral dermatitis is an acneiform eruption commonly occuring around the mouth, nose, eyes or perianal area in children and adults. Less commonly, the condition may present with granulomatous papules with a red, yellow color.

What you should be alert for in the history

A history should be taken to rule out etiologic factors such as use of topical or oral steroids and to rule out other conditions in the differential diagnosis with the most common being allergic or irritant contact dermatitis (such as lip lickers dermatitis), acne or eczema. Particular attention should be paid to any topical agents that may have been applied to the affected area, including medications (especially steroids) and cosmetics (for a possible contact dermatitis). Recurrent perinasal dermatitis can be associated with Staphylococcus in the nares.

Characteristic findings on physical examination

Characteristic findings on physical examination include acneiform papules, pustules, erythema or scaling in a periorficial distribution that spares other areas of the face or skin (Figure 1, Figure 2).

Expected results of diagnostic studies

In cases where the clinical diagnosis is unclear a potassium hydroxide (KOH) preparation can be performed to rule out candida or tinea. Bacterial or viral cultures can be taken. A Tzanck preparation or direct fluorescent antigen (DFA) test can be performed to rule out herpes. If the history suggests a contact allergen, patch testing can be performed. If the diagnosis of sarcoid is considered, a skin biopsy can be obtained. Serum levels of zinc or glucagon and/or skin biopsy can be used to rule out zinc deficiency or necrolytic migratory erythema if the diagnosis can’t be made clinically.

Diagnosis confirmation

Other conditions in the differential diagnosis include lip lickers dermatitis, characterized by erythematous scaling patches often involving the margin of the lower lip or the entire lips with a fairly well-defined border; rosacea, which usually has papules, pustules and telangiectasia involving the cheeks; candida infection (perleche) that presents with patches of erythema, white exudate and fissures at the corners of the mouth; bacterial infection with Staphylococcus or Streptococcus that can be associated with honey colored crusting as in impetigo; viral infection with herpes simplex or rarely cytomegalovirus that presents with periorificial blisters; seborrheic dermatits, which presents with erythematous patches with greasy scale often involving the nasolabial folds, eyebrows, retroauricular area and scalp in adults and the scalp and diaper area in children; tinea infection, which presents with annular erythematous patches with well-demarkated scaling borders; and sarcoid, which presents with granulomatous papules.

Rare conditions in the differential diagnosis of periorificial dermatitis include acrodermatitis enteropathica, a cutaneous manifestation of zinc deficiency; and necrolytic migratory erythema associated with glucagonoma and characterized by erythematous scaling patches, vesicles, crust, and fissures.

Who is at Risk for Developing this Disease?

Perioral dermatitis commonly occurs in patients using inhaled steroids, topical steroids or systemic steroids. In a series of 79 children and adolescents with periorificial dermatitis, 72% had used inhaled, topical, or systemic steroids. The distribution of the rash was perioral in 70%, perinasal in 43%, periocular in 25% and perivulvar in 1%. In adults, perioral dermatitis commonly occurs in young women and in many cases cannot be linked to use of a particular product.

What is the Cause of the Disease?

Etiology

Pathophysiology

Apart from known triggers such as steroids or contact allergy, little is known regarding the etiology or pathophysiology of periorificial dermatitis. The condition is commonly recurrent with periods of spontaneous resolution and periodic exacerabations.

Systemic Implications and Complications

Periorificial dermatitis itself is not associated with any systemic effects or complications.

Treatment Options

Topical therapies

Metronidazole

Azelaic acid

Pimecrolimus

Tacrolimus

Sodium sulfacetamide

Clindamycin

Erythromycin

Benzoyl peroxide/clindamycin or erythromycin combination products

Adapalene

Tretinoin

Hydrocortisone

Systemic therapies

Tetracycline

Doxycycline

Erythromycin

Minocycline

Isotretinoin

Optimal Therapeutic Approach for this Disease

Evidence-based data regarding treatment of periorificial dermatitis is limited. Most cases resolve spontaneously. A first-line approach is to discontinue offending agents such as steroids or contact allergens if possible. There are no drugs approved by the U.S. Food and Drug Administration for periorificial dermatitis. A recent evidence-based review supports use of no therapy, topical pimecrolimus oral tetracycline and topical erythromycin.

Typically, initial therapy for mild disease consists of a topical medication such as metronodazole gel or cream or azelaic acid gel applied once or twice daily. Topical calcineurin inhibitors, such as pimecrolimus 1% cream twice daily, have been used with mixed results. Some cases of exacerbation or induction of perioral dermatitis have been reported with calcineurin inhibitors.

Other topical agents with limited reports of benefit include sodium sulfacetamide lotion 10%, clindamycin lotion or gel, and benzoyl peroxide/antibiotic combination products. In one case, benefit was reported with use of topical adapalene 0.1% gel. If a response to topical therapy is not noted in 4-8 weeks, systemic therapy can be added.

For more extensive or persistent cases, therapy can be initiated with an oral antibiotic with or without a topical agent. Oral erythromycin is best for children under the age of 8-10, as tetracyclines can lead to staining of the permanent teeth. In adults, tetracycline 500mg twice daily or doxycycline 100mg once or twice daily can be used for 4-8 weeks. Minocycline up to 100mg twice a day is generally used in cases that fail to respond to other members of the tetracycline family, due to potential side effects.

In cases where the patient has not used topical steroids or fails to respond to other topical or systemic agents, hydrocortisone can be used for a brief period of time (2-4 weeks). Oral isotretinoin has been reported to be beneficial in severe cases of treatment-resistant granulomatous perioral dermatitis. Use of isotretinoin in the United States is reserved for physicians registered in the iPLEDGE system.

Patient Management

Patients are generally followed within 4-6 weeks to monitor for a therapeutic response. In cases due to steroid use, a response may take up to 2 months or more after the steroid is discontinued. For persistent cases that require ongoing or maintenance therapy it is best to avoid long-term use of antibiotics, due to concerns regarding the development of antibiotic-resistant bacteria.

Unusual Clinical Scenarios to Consider in Patient Management

In some cases, it is not possible for a patient to discontinue steroids. If inhaled steroids are used, patients can be instructed to wash the perioral area as soon as possible after use of the medication. If use of long-term topical antibiotics are needed, it may be best to combine this treatment with use of a benzoyl peroxide to help reduce antibiotic resistant bacteria on the skin surface.

What is the Evidence?

Boeck, K, Abeck, D, Werfel, S, Ring, J. “Perioral dermatitis in children – clinical presentation, pathogenesis-related factors and response to topical metronidazole”. Dermatology. vol. 195. 1997. pp. 235-8. (This review of perioral dermatitis discusses the authors' experience with treatment in children with metronidazole. It reviews the pathogenesis, epidemiology, and gives therapeutic options.)

Hall, CS, Reichenberg, J. “Evidence-based review of perioral dermatitis therapy”. G Ital Dermatol Venereol. vol. 145. 2010. pp. 433-44. (A review of medications that have been studied for the treatment of perioral dermatitis.)

Jansen, T. “Azelaic acid as a new treatment for perioral dermatitis: results from an open study”. Br J Dermatol. vol. 151. 2004. pp. 933-4. (This open-labeled study showed that azelaic acid can be used with efficacy in the treatment of perioral dermatitis.)

Nguyen, V, Eichenfield, LF. “Periorificial dermatitis in children and adolescents”. J Am Acad Dermatol. vol. 55. 2006. pp. 781-5. (Discusses the diagnosis and clinical presentation along with therapeutic options for children with perioral dermatitis.)

Oppel, T, Pavicic, T, Kamann, S, Braütigam, 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. vol. 21. 2007. pp. 1175-80. (Double-blinded study showing the efficacy of pimecrolimus cream in the treatment of perioral dermatitis.)

Schwarz, T, Kreiselmaier, I, Bieber, T, Thaci, D, Simon, JC, Meurer, M. “A randomized, double-blind, vehicle-controlled study of 1% pimecrolimus cream in adult patients with perioral dermatitis”. J Am Acad Dermatol. vol. 59. 2008. pp. 34-40. (Another double-blinded study showing the efficacy of pimecrolimus cream for the treatment of adult perioral dermatits.)

Veien, NK, Munkvad, JM, Nielsen, AO, Niordson, AM, Stahl, D, Thormann, J. “Topical metronidazole in the treatment of perioral dermatitis”. J Am Acad Dermatol. vol. 24. 1991. pp. 258-60. (Older study that showed topical metronidazole is efficacious in the treatment of perioral dermatitis.)

Weber, K, Thurmayr, R. “Critical appraisal of reports on the treatment of perioral dermatitis”. Dermatology. vol. 210. 2005. pp. 300-7. (Overview paper reviewing the therapeutic options available for perioral dermatitis. Excellent resource.)

Yung, A, Highet, AS. “Perioral dermatitis and inadvertent topical corticosteroid exposure”. Br J Dermatol. vol. 147. 2002. pp. 1264-81. (Article discussing the importance of topical steroids in the pathogenesis of perioral dermatitis.)

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