Perioral Dermatitis

Aka: Perioral Dermatitis, Periorificial Dermatitis, Perioral Acne, Acneiform Facial Eruption

1. See Also
   1. Acne Rosacea
   2. Acne Vulgaris
2. Definitions
   1. Perioral Acne
      1. Acneiform eruption of inflammed Papules in the region of the eyes, nose and mouth
   2. Acneiform Facial Eruption
      1. Acne-like facial dermatitis from facial Acne Vulgaris, Rosacea, Folliculitis, or Perioral Dermatitis
      2. See Differential Diagnosis below
3. Epidemiology
   1. Gender: Most common in women
   2. Age: Typically late teen to 40-50 years old
      1. But may occur in children and older adults
4. Pathophysiology
   1. Poorly understood
   2. Associated factors
      1. Topical agents (Topical Corticosteroids, fluoridated toothpaste, Skin Lubricants and cosmetics)
      2. Hormonal fluctuations and Oral Contraceptives
      3. Infectious agents including fusobacteria and Candida Albicans
5. Risk Factors
   1. Topical Corticosteroids (esp. potent or fluorinated Corticosteroids)
      1. Prolonged Corticosteroid use on the face is the most commonly associated factor
      2. However, lesions often initially worsen on discontinuing the Topical Corticosteroids
   2. Fluoridated Toothpaste
   3. Skin Lubricants (esp. if containing perfumes or dyes)
   4. Cosmetics
   5. Oral Contraceptives
6. Differential Diagnosis: Acneiform Facial Eruption
   1. Acne Rosacea
   2. Acne Vulgaris
   3. Seborrheic Dermatitis
   4. Irritant Contact Dermatitis
   5. Allergic Contact Dermatitis
   6. Tinea Corporis
   7. Tinea Barbae
   8. Impetigo
   9. Superficial Folliculitis (less common)
      1. Gram-Negative Folliculitis
      2. Eosinophilic Folliculitis (may be associated with HIV Infection)
7. Symptoms
   1. Mild stinging or burning pain may occur over involved region
8. Signs
   1. Characteristics
      1. Small (1-2 mm), erythematous Papules, Pustules or Vesicles
      2. Mild scale may be present
   2. Distribution
      1. Perioral region (most common)
         1. Narrow band of sparing immediately around the region of the lips
      2. Perinasal region (common)
      3. Periorbital region (common)
      4. Forehead
      5. Cheeks
      6. Chin
      7. Neck
9. Associated Conditions: Variants
   1. Eczematous Dermatitis
      1. Mild Eczema may accompany the Perioral Dermatitis
      2. However, typical Perioral Dermatitis is not Eczematous
   2. Granulomatous Periorificial Dermatitis (known as Afro-Caribbean Childhood Eruption in black children)
      1. Variant in pre-pubescent children
      2. Small flesh or brown colored Papules (but no Pustules) in same distribution as typical Perioral Dermatitis
10. Management
    1. Eliminate topical irritants and allergans
       1. Stop Topical Corticosteroids
          1. Expect an initial Perioral Dermatitis flare
          2. May taper off the Corticosteroid, or briefly step down to Hydrocortisone 1% before stopping
       2. Limit topical agents on the face
          1. Use only hypoallergenic non-soaps on the face (e.g. Cetaphil Skin Cleanser)
       3. Stop topical agents on the face (cosmetics, Skin Lubricants and other occlusive agents)
          1. May sparingly use hypoallergenic (non-perfume, no dye), non-occlusive Skin Lubricants
       4. Once resolved or controlled, may slowly re-introduce hypoallergenic topical agents
          1. Re-introduce one product per week
    2. Topical Agents
       1. Topical Erythromycin 2% gel applied twice weekly
       2. Topical Metronidazole 0.75% gel, lotion or cream once to twice daily
       3. Topical Pimecrolimus 1% cream applied twice daily
          1. See Calcineurin Inhibitor regarding potential malignancy risk
    3. Systemic Agents (for moderate to severe, refractory Perioral Dermatitis)
       1. Tetracyclines
          1. Tetracycline 250 to 500 mg orally twice daily
          2. Doxycyline 50 to 100 mg orally twice daily (or 100 mg once daily)
       2. Erythromycin (children <8 years old and pregnant women)
          1. Adults: Erythromycin base 333 mg three times daily or 500 mg orally twice daily
    4. Other measures: Acneiform Facial Eruption
       1. Consider differential diagnosis
       2. Consider treating as Acne Vulgaris with Comedolytics
11. Course
    1. Variable, but typically heals without scarring
    2. Some cases spontaneously resolve in months
    3. Other cases require several years of topical therapy
12. References
    1. Reichenberg (2019) Perioral Dermatitis, UpToDate, accessed 6/15/2019
    2. (2002) Am Fam Physician 66(3):479-480 [PubMed]
    3. Cheung (2005) Can Fam Physician 51(4): 527–533 +PMID:15856972 [PubMed]