Perioral dermatitis, also known as periorificial dermatitis, is a common type of

skin rash A rash is a change of the human skin which affects its color, appearance, or texture. A rash may be localized in one part of the body, or affect all the skin. Rashes may cause the skin to change color, itch, become warm, bumpy, chapped, dry, cr ...

. Symptoms include multiple small (1–2 mm)

bumps A bumps race is a form of rowing race in which a number of boats chase each other in single file, each crew attempting to catch and ‘bump’ the boat in front without being caught by the boat behind. The form is mainly used in intercollegia ...

and

blisters A blister is a small pocket of body fluid ( lymph, serum, plasma, blood, or pus) within the upper layers of the skin, usually caused by forceful rubbing ( friction), burning, freezing, chemical exposure or infection. Most blisters are filled ...

sometimes with background redness and scale, localized to the skin around the

mouth In animal anatomy, the mouth, also known as the oral cavity, or in Latin cavum oris, is the opening through which many animals take in food and issue vocal sounds. It is also the cavity lying at the upper end of the alimentary canal, bounded on ...

and nostrils. Less commonly the

eyes Eyes are organs of the visual system. They provide living organisms with vision, the ability to receive and process visual detail, as well as enabling several photo response functions that are independent of vision. Eyes detect light and con ...

and

genitalia A sex organ (or reproductive organ) is any part of an animal or plant that is involved in sexual reproduction. The reproductive organs together constitute the reproductive system. In animals, the testis in the male, and the ovary in the female, a ...

may be involved. It can be persistent or recurring and resembles particularly

rosacea Rosacea is a long-term skin condition that typically affects the face. It results in redness, pimples, swelling, and small and superficial dilated blood vessels. Often, the nose, cheeks, forehead, and chin are most involved. A red, enlarg ...

and to some extent

acne Acne, also known as ''acne vulgaris'', is a long-term skin condition that occurs when dead skin cells and oil from the skin clog hair follicles. Typical features of the condition include blackheads or whiteheads, pimples, oily skin, and ...

and allergic dermatitis. The term "dermatitis" is a misnomer because this is not an eczematous process. The cause is unclear.

Topical steroids Topical steroids are the topical forms of corticosteroids. Topical steroids are the most commonly prescribed topical medications for the treatment of rash, eczema, and dermatitis. Topical steroids have anti-inflammatory properties and are classifie ...

are associated with the condition and

moisturizers A moisturizer, or emollient, is a cosmetic preparation used for protecting, moisturizing, and lubricating the skin. These functions are normally performed by sebum produced by healthy skin. The word "emollient" is derived from the Latin verb ''m ...

and

cosmetics Cosmetics are constituted mixtures of chemical compounds derived from either natural sources, or synthetically created ones. Cosmetics have various purposes. Those designed for personal care and skin care can be used to cleanse or protec ...

may contribute. The underlying mechanism may involve blockage of the skin surface followed by subsequent excessive growth of

skin flora Skin flora, also called skin microbiota, refers to microbiota ( communities of microorganisms) that reside on the skin, typically human skin. Many of them are bacteria of which there are around 1,000 species upon human skin from nineteen phyla.P ...

. Fluoridated

toothpaste Toothpaste is a paste or gel dentifrice used with a toothbrush to clean and maintain the aesthetics and health of teeth. Toothpaste is used to promote oral hygiene: it is an abrasive that aids in removing dental plaque and food from the teeth, ...

and some micro-organisms including ''Candida'' may also worsen the condition, but their roles in this condition are unclear. It is considered a disease of the

hair follicle The hair follicle is an organ found in mammalian skin. It resides in the dermal layer of the skin and is made up of 20 different cell types, each with distinct functions. The hair follicle regulates hair growth via a complex interaction between ...

with

biopsy A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist. The process involves extraction of sample cells or tissues for examination to determine the presence or extent of a dise ...

samples showing

microscopic The microscopic scale () is the scale of objects and events smaller than those that can easily be seen by the naked eye, requiring a lens or microscope to see them clearly. In physics, the microscopic scale is sometimes regarded as the scale be ...

changes around the hair follicle. Diagnosis is based on symptoms. Treatment is typically by stopping topical steroids, changing cosmetics, and in more severe cases, taking

tetracyclines Tetracyclines are a group of broad-spectrum antibiotic compounds that have a common basic structure and are either isolated directly from several species of ''Streptomyces'' bacteria or produced semi-synthetically from those isolated compounds. T ...

by mouth. Stopping steroids may initially worsen the rash. The condition is estimated to affect 0.5-1% of people a year in the developed world. Up to 90% of those affected are women between the ages of 16 and 45 years, though it also affects children and the elderly, and has an increasing incidence in men.

History

The disorder appears to have made a sudden appearance with a case of 'light sensitive seborrhoeid' in 1957, which is said to be the first nearest description of the condition. By 1964, the condition in adults became popularly known as perioral dermatitis, but without clear clinical criteria. In 1970, the condition was recognised in children. That all rashes around the mouth are perioral dermatitis has since been frequently debated. That this condition should be renamed periorificial dermatitis has been proposed.

Darrell Wilkinson Peter Edward Darrell Sheldon Wilkinson (7 August 1919 – 17 August 2009) was a leading figure in dermatology who was consultant at Aylesbury and High Wycombe, co-edited the first edition of Rook's 1968 '' Textbook of Dermatology'' and found ...

, 1919–2009, was a British dermatologist who gave one of the earliest 'definitive' descriptions of 'perioral dermatitis' and noted that the condition was not always associated with the use of fluoridated steroid creams.

Signs and symptoms

A stinging and burning sensation with rash is often felt and noticed, but itching is less common. Often the rash is steroid responsive, initially improving with application of topical steroid. The redness caused by perioral dermatitis has been associated with variable level of depression and

anxiety Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...

. Initially, there may be small pinpoint papules either side of the nostrils. Multiple small (1-2mm) papules and pustules then occur around the mouth, nose and sometimes cheeks. The area of skin directly adjacent to the lips, also called the vermillion border, is spared and looks normal. There may be some mild background redness and occasional scale. These areas of skin are felt to be drier and therefore there is a tendency to moisturise them more frequently. Hence, they do not tolerate drying agents well and the rash can be worsened by them. Perioral dermatitis is also known by other names including rosacea-like dermatoses, periorofacial dermatitis and periorificial dermatitis. Unlike rosacea which involves mainly the nose and cheeks, there is no

telangiectasia Telangiectasias, also known as spider veins, are small dilated blood vessels that can occur near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter. These dilated blood vessels can develop anywhere on ...

in perioral dermatitis. Rosacea also has a tendency to be present in older people. Acne can be distinguished by the presence of

comedones A comedo is a clogged hair follicle (pore) in the skin. Keratin (skin debris) combines with oil to block the follicle. A comedo can be open (blackhead) or closed by skin (whitehead) and occur with or without acne. The word "comedo" comes from the ...

and by its wider distribution on the face and chest. There are no comedones in perioral dermatitis.

Causes

The cause of perioral dermatitis is unclear. The use of topical steroids and cosmetics have the most important role. Although light exposure has been discounted as a causal factor, some reports of perioral dermatitis have been made by some patients receiving Psoralen and ultraviolet A therapy.

Corticosteroids

Perioral dermatitis often happens after the use of topical steroids on the face, and is more likely to occur the greater the strength of topical steroid used. Discontinuing the steroids often initially worsens the dermatitis, and dependency on the steroids can occur as people believe the steroids were initially controlling the condition. Inhaled corticosteroids may also trigger perioral dermatitis. Perioral dermatitis has a tendency to occur on the drier parts of the face and can be aggravated by drying agents including topical benzoyl peroxide, tretinoin and lotions with an alcohol base.

Immunosuppressants

Reports of perioral dermatitis in renal transplant recipients treated with oral corticosteroids and azathioprine have been documented.

Cosmetics

Cosmetics play an important role as causal factors for perioral dermatitis. Regular generous applications of moisturising creams cause persistent hydration of the layer causing impairment and occlusion of the barrier function, irritation of the hair follicle, and proliferation of skin flora. Combining this with night cream and foundation significantly increases risk of perioral dermatitis 13-fold.

Micro-organisms

Topical corticosteroids may lead to increase micro-organism density in the hair follicle. The role of infectious agents such as ''Candida'' species, ''

Demodex folliculorum ''Demodex folliculorum'' is a microscopic mite that can only survive on the skin of humans. Most people have ''D.folliculorum'' on their skin. Usually, the mites do not cause any harm, so are considered an example of commensalism rather than par ...

'', and fusiform bacteria has not been confirmed.

Psychosocial

As a cosmetic impairment, perioral dermatitis is increasingly documented to have psychosocial aspects to its cause and clinical findings. Specific personality structures, professions and social habits have been implicated in the type of person the condition occurs in.

Other potential causes

The condition may be potentially worsened by fluoridated toothpaste and inhaled corticosteroids. A high prevalence of atopy has been found in those with perioral dermatitis. The possibility of an association with the wearing of the veil in Arab women has been documented.

Pathophysiology

The pathophysiology of perioral dermatitis is related to disease of the hair follicle as is now included in the

ICD-11 The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World H ...

due to be finalised in 2018.

Lip licker's dermatitis Lip licker's dermatitis is a type of skin inflammation around the lips due to damage by saliva from repetitive lip licking and is classified as a subtype of irritant contact cheilitis. The resulting scaling, redness, chapping, and crusting makes ...

or perioral irritant contact dermatitis due to lip-licking is considered a separate disease categorised under irritant contact dermatitis due to saliva. Perioral dermatitis is frequently histologically similar to rosacea with the two conditions overlapping considerably. There is a lymphohistiocytic infiltrate with perifollicular localization and marked granulomatous inflammation. Occasionally, perifollicular abscesses may be present when pustules and papules are the dominant clinical findings.

Diagnosis

A diagnosis of perioral dermatitis is typically made based on the characteristics of the rash. A skin biopsy is usually not required to make the diagnosis but can be helpful to rule out other skin diseases which may resemble perioral dermatitis. Extended patch testing may be useful to also rule out allergic contact causes. Other skin diseases that may resemble perioral dermatitis include: *

Rosacea Rosacea is a long-term skin condition that typically affects the face. It results in redness, pimples, swelling, and small and superficial dilated blood vessels. Often, the nose, cheeks, forehead, and chin are most involved. A red, enlarg ...

Acne vulgaris Acne, also known as ''acne vulgaris'', is a long-term skin condition that occurs when dead skin cells and oil from the skin clog hair follicles. Typical features of the condition include blackheads or whiteheads, pimples, oily skin, and po ...

Seborrheic dermatitis Seborrhoeic dermatitis, sometimes inaccurately referred to as seborrhoea, is a long-term skin disorder. Symptoms include red, scaly, greasy, itchy, and inflamed skin. Areas of the skin rich in oil-producing glands are often affected including the ...

* Allergic

contact dermatitis Contact dermatitis is a type of acute or chronic inflammation of the skin caused by exposure to chemical or physical agents. Symptoms of contact dermatitis can include itchy or dry skin, a red rash, bumps, blisters, or swelling. These rashes are ...

* Irritant contact dermatitis *

Angular cheilitis Angular cheilitis (AC) is inflammation of one or both corners of the mouth. Often the corners are red with skin breakdown and crusting. It can also be itchy or painful. The condition can last for days to years. Angular cheilitis is a type of ch ...

Treatment

Multiple treatment regimes are available and treatment algorithms have been proposed. Perioral dermatitis will usually resolve within a few months without medication, by limiting the use of irritants, including products with fragrance, cosmetics, benzoyl peroxide, occlusive sunscreens, and various acne products. This is called zero treatment. Topical corticosteroids should be stopped entirely if possible. If the flare proves intolerable, temporary use of a less potent topical corticosteroid can often be helpful.

Medication

A number of medications, either applied directly to the skin or taken by mouth, may hasten recovery. These include

tetracycline Tetracycline, sold under various brand names, is an oral antibiotic in the tetracyclines family of medications, used to treat a number of infections, including acne, cholera, brucellosis, plague, malaria, and syphilis. Common side effects in ...

doxycycline Doxycycline is a broad-spectrum tetracycline class antibiotic used in the treatment of infections caused by bacteria and certain parasites. It is used to treat bacterial pneumonia, acne, chlamydia infections, Lyme disease, cholera, typhus ...

, and

erythromycin Erythromycin is an antibiotic used for the treatment of a number of bacterial infections. This includes respiratory tract infections, skin infections, chlamydia infections, pelvic inflammatory disease, and syphilis. It may also be used durin ...

.U.S. National Library of Medicine (December 11, 2009
'Perioral dermatitis'
Retrieved August 7, 2010. Erythromycin may be used as a cream. Doxycycline is most often the first antibiotic drug choice, given at a daily dosage of 100 mg for up to a month before considering tapering off or stopping. Sometimes, longer duration of low doses of doxycycline are required. Metronidazole is less effective, but is available in a gel and can be applied twice daily. If the perioral dermatitis was triggered by a topical steroid then pimecrolimus cream has been suggested as effective in improving symptoms. However, this has also been documented to cause the condition.

Prognosis

Perioral dermatitis is likely to fully resolve with short courses of antibiotics but if left untreated it can persist for years and take a chronic form. Improvement with tetracyclines is usually seen after 4 days and significantly so after 2 weeks.

Epidemiology

Most commonly in women between the ages of 16 and 45 years, perioral dermatitis also occurs equally in all racial and ethnic backgrounds and include children as young as three months and is increasingly reported in men. In children, females are more likely affected. It has an incidence of up to 1% in developed countries.

References

{{DEFAULTSORT:Perioral Dermatitis Acneiform eruptions