Follicular skin diseases
- Be able to recognise and manage a straightforward case of perioral dermatitis.
- Perioral dermatitis occurs around the mouth, and periorificial dermatitis around an orifice (mouth, nose, eyes, vagina, anus).
- The primary lesion is an erythematous papule or patch.
- Topical steroids and occlusive preparations must be discontinued.
- Stopping topical steroid may result in flare-up.
- Perioral dermatitis usually clears with one to three months of oral antibiotics.
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.
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.
Mild perioral dermatitis: scaly papules
Typical perioral dermatitis: papules and erythema
Perioral dermatitis: papules and pustules
Papules clustered on the bridge of the nose between the eyes
Genital periorificial dermatitis
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
Perioral dermatitis appears to be due to activation of innate immune pathways and changes to facial microbiome.
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.
- 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 50–100 mg or minocycline 50–100 mg 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.