Perioral dermatitis

Perioral dermatitis is an inflammatory skin condition characterized by erythematous papules and pustules around the mouth that spare the lips. The etiology is unclear, but perioral dermatitis is associated with corticosteroid use and cosmetic products. Diagnosis is usually clinical, although diagnostic testing may be performed to rule out differential diagnoses (e.g., KOH test for fungal infections, patch test for allergic contact dermatitis). Treatment involves cessation of topical corticosteroid and cosmetic use. Topical and oral pharmacotherapy (e.g., antibiotics) may be used in moderate and severe perioral dermatitis.

• Primarily affects women 16–45 years of age ^[1]
• May also affect children

Epidemiological data refers to the US, unless otherwise specified.

Unclear; proposed causes include: ^[1][2]

• Corticosteroid use (topical, systemic, and inhaled)
• Cosmetic and sunscreen use
• Infection (e.g., Fusobacterium spp., Candida albicans)
• Hormonal factors (e.g., pregnancy, oral contraceptives)

• Distribution
  • Typically around the mouth, sparing the vermilion border
  • Areas around other orifices (eyes, genitals) may also be affected (periorificial dermatitis). ^[2]
• Lesions
  • Small clusters of erythematous papules and pustules ^[3]
  • Skin erythema and/or scaling
  • Flesh-colored or yellow-brown papules (granulomatous periorificial dermatitis) may be visible, especially in children of color. ^[4]
• Symptoms may include:
  • Burning
  • Tenderness
  • Pruritus
• May persist for months to years ^[3]

• Diagnosis is clinical. ^[1]
• Diagnostic uncertainty: Consider testing to rule out differential diagnoses of perioral dermatitis. ^[1]
  • KOH test: for fungal infections
  • Culture: for bacterial and/or fungal infections
  • Patch test: for allergic contact dermatitis
  • Skin biopsy ^[1][2]

• Rosacea
• Acne vulgaris
• Mask acne
• Steroid acne
• Lupus miliaris disseminatus faciei
• Seborrheic dermatitis
• Atopic dermatitis
• Allergic contact dermatitis
• Irritant contact dermatitis

The differential diagnoses listed here are not exhaustive.

• All patients: Initiate conservative treatment. ^[7][2]
  • Discontinue topical steroids. ^[1]
  • Advise patients to avoid potential skin allergens and irritants, e.g., cosmetics.
• Moderate dermatitis : Initiate topical therapy with either of the following options. ^[7][2]
  • Topical antibiotics, e.g., metronidazole (off-label) ^[6]
  • Pimecrolimus (off-label) ^[3][8]
• Severe dermatitis : ^[7]
  • Nonpregnant adults and children ≥ 8 years of age: oral tetracycline (off-label) ^[1]
  • Children < 8 years of age: oral erythromycin (off-label) ^[1]
• Refractory dermatitis: Consider referral to dermatology.

While corticosteroids may temporarily reduce lesions, they should be avoided because both continuous use and discontinuation of corticosteroids are associated with worsening of disease. ^[3]