Perioral Dermatitis

Introduction | Aetiology and Risk Factors | Clinical Presentation | Diagnosis | Management and Treatment | Prevention | When to Refer | References

Introduction

Perioral dermatitis is a common facial skin condition that presents as a rash around the mouth, nose, and sometimes the eyes. It is characterised by small, red or flesh-coloured papules that may be itchy or burning. The condition primarily affects young women but can occur in all ages and genders. While the exact cause is unknown, perioral dermatitis is often associated with the use of topical steroids or other facial products.

Aetiology and Risk Factors

Perioral dermatitis has several potential triggers and risk factors, including:

• Topical Steroids: The use of topical corticosteroids, particularly potent ones, is strongly associated with the development of perioral dermatitis. The condition often appears after the discontinuation of steroids.
• Facial Products: Overuse of heavy creams, moisturisers, or cosmetics can contribute to the development of perioral dermatitis by irritating the skin.
• Hormonal Changes: Fluctuations in hormones, such as those related to the menstrual cycle, pregnancy, or contraceptive use, can trigger perioral dermatitis.
• Environmental Factors: Exposure to harsh weather, wind, or sun, as well as excessive sweating, can exacerbate the condition.
• Infection: Although rare, certain bacterial or fungal infections can mimic or exacerbate perioral dermatitis.
• Age and Gender: It is more common in women aged 16-45, though it can occur in men and children.

Clinical Presentation

The clinical features of perioral dermatitis include:

• Papules and Pustules: Small, red or flesh-coloured bumps that may contain pus are typically found around the mouth, nasolabial folds, and sometimes the eyes.
• Itching or Burning: The affected areas may feel itchy, tender, or have a burning sensation, though pain is uncommon.
• Sparing of the Vermilion Border: The rash usually spares the area immediately around the lips, leaving a clear zone between the lips and the rash.
• Dryness and Scaling: The skin may appear dry and flaky, particularly as the rash begins to heal.
• Absence of Comedones: Unlike acne, perioral dermatitis does not typically feature blackheads or whiteheads.

Diagnosis

The diagnosis of perioral dermatitis is primarily clinical, based on the characteristic appearance and distribution of the rash:

• History: Take a detailed history of any topical steroid use, facial products, and any recent changes in skincare routines or hormonal medications.
• Physical Examination: Examine the distribution and appearance of the rash, noting the typical sparing of the vermilion border.
• Differential Diagnosis: Consider other conditions such as acne vulgaris, rosacea, seborrhoeic dermatitis, or allergic contact dermatitis, which may present with similar features.
• Microbiological Testing: If infection is suspected, a swab for bacterial or fungal culture may be performed, though this is not routinely required.

Management and Treatment

Management of perioral dermatitis focuses on eliminating triggers, providing symptomatic relief, and treating the underlying inflammation:

1. Discontinuing Triggers

• Stop Topical Steroids: Discontinuation of topical steroids is essential. Be aware that symptoms may temporarily worsen after stopping steroids, known as steroid withdrawal or rebound.
• Avoid Irritating Products: Advise patients to stop using heavy creams, moisturisers, and other facial products that could exacerbate the condition. Opt for gentle, non-comedogenic cleansers and moisturisers.

2. Topical Treatments

• Metronidazole Gel or Cream: This is a commonly prescribed topical treatment that has anti-inflammatory and antimicrobial properties. Apply twice daily to the affected area.
• Azelaic Acid: An alternative topical treatment that helps reduce inflammation and redness. It is often well-tolerated and can be used in conjunction with other therapies.
• Clindamycin Gel: A topical antibiotic that can be used if bacterial involvement is suspected or in cases unresponsive to other treatments.
• Pimecrolimus Cream: A topical calcineurin inhibitor that can be used as a steroid-sparing agent to reduce inflammation.

3. Oral Treatments

• Tetracycline Antibiotics: Oral tetracyclines such as doxycycline or lymecycline are often used for more severe cases of perioral dermatitis. These antibiotics have anti-inflammatory properties in addition to their antimicrobial effects.
• Macrolide Antibiotics: If tetracyclines are contraindicated (e.g., in pregnancy or in young children), macrolides like erythromycin may be used as an alternative.
• Course Duration: Oral antibiotics are typically prescribed for 6-8 weeks, with gradual tapering once symptoms improve.

4. Supportive Care

• Moisturisers: Use light, non-comedogenic moisturisers to help soothe dry skin. Avoid heavy creams that can clog pores and exacerbate the condition.
• Sun Protection: Sunscreen is important, but choose a physical (mineral) sunscreen with zinc oxide or titanium dioxide, which is less likely to irritate sensitive skin.
• Gentle Skincare Routine: Advise patients to cleanse the face with mild, soap-free cleansers and avoid scrubbing or exfoliating the skin.

Prevention

Preventive strategies can help reduce the risk of recurrence of perioral dermatitis:

• Avoid Topical Steroids: Refrain from using topical steroids on the face unless absolutely necessary, and only under medical supervision.
• Gentle Skincare Routine: Maintain a skincare routine using gentle, fragrance-free, non-comedogenic products.
• Avoid Heavy Cosmetics: Minimise the use of heavy makeup or oil-based products that can clog pores.
• Monitor Hormonal Triggers: If hormonal changes are a suspected trigger, discuss management options with a healthcare provider, particularly in relation to contraceptive use.
• Sun Protection: Regular use of appropriate sunscreen to protect the skin from UV damage, which can exacerbate skin conditions.

When to Refer

Referral to a dermatologist may be necessary in the following situations:

• Severe or Refractory Cases: If perioral dermatitis does not respond to standard treatments, referral to a specialist for further evaluation and management is advised.
• Uncertain Diagnosis: If the diagnosis is unclear or if the presentation is atypical, a dermatologist's input may be required to rule out other conditions.
• Complications: In cases where secondary infection, significant scarring, or other complications arise, specialist care may be necessary.
• Consideration for Alternative Therapies: If standard treatments are ineffective or contraindicated, a specialist may consider alternative therapies such as isotretinoin.

References

1. British Association of Dermatologists (2024) Guidelines for the Management of Perioral Dermatitis. Available at: https://www.bad.org.uk (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Perioral Dermatitis: Diagnosis and Management. Available at: https://www.nice.org.uk/guidance/ng106 (Accessed: 26 August 2024).
3. British National Formulary (2024) Topical and Oral Treatments for Dermatological Conditions. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).