What is the diagnosis and treatment for perioral dermatitis?

From the Guidelines

Perioral dermatitis should be treated with topical metronidazole 0.75% cream applied twice daily for 8-12 weeks, and oral antibiotics such as doxycycline 100mg once or twice daily for 4-8 weeks may be necessary for moderate to severe cases. Perioral dermatitis is a common inflammatory skin condition characterized by small red bumps, pustules, and mild scaling around the mouth, nose, and sometimes eyes.

Key Considerations

• Treatment typically involves a combination of topical and oral medications
• Topical steroids and heavy moisturizers should be avoided as they can worsen the condition, as they may cause perioral dermatitis and skin atrophy if used inadequately 1
• A gentle skincare routine using mild, fragrance-free cleansers and avoiding occlusive cosmetics is recommended
• The condition likely results from altered skin microbiome, follicular dysfunction, and barrier disruption
• Improvement typically begins within 2-4 weeks of treatment, but complete resolution may take several months
• Recurrence is common, so maintenance therapy with topical treatments may be needed

Treatment Approach

• First-line therapy: topical metronidazole 0.75% cream applied twice daily for 8-12 weeks
• Moderate to severe cases: oral antibiotics such as doxycycline 100mg once or twice daily for 4-8 weeks may be necessary
• Patients should be reassured that while perioral dermatitis can be frustrating and persistent, it is not dangerous and can be effectively managed with appropriate treatment and skincare modifications. Some key points to consider when treating perioral dermatitis include:
• Avoiding greasy creams for basic care, as they might facilitate the development of folliculitis due to their occlusive properties 1
• Avoiding manipulation of skin, as it may increase the risk of infection 1
• Avoiding hot blow-drying of the hair, wearing of tight shoes, and other factors that may exacerbate the condition 1

From the Research

Diagnosis of Perioral Dermatitis

• Perioral dermatitis is a common and often chronic dermatosis that primarily affects women aged 15 to 45 years 2
• The disease has variants, including lupus-like and granulomatous perioral dermatitis, with the granulomatous form being more common in childhood and affecting mostly prepubescent boys 2
• The etiopathogenesis of the disease remains unclear, but prolonged use of topical products, especially corticosteroids, is a frequent finding preceding the clinical manifestation of perioral dermatitis 2, 3
• Clinical presentation of papulovesicular eruption in the perioral region with a typical narrow spared zone around the edge of the lips is characteristic 2
• Differential diagnosis includes seborrheic dermatitis, systemic lupus erythematosus, acne vulgaris, lupus miliaris disseminatus faciei, steroid-induced rosacea, and basal cell carcinoma 4

Treatment of Perioral Dermatitis

• Therapeutic approach should be individually addressed, depending on the severity of clinical presentation and patient's age, with special attention to patient's education and continuous psychological support 2
• In mild forms of perioral dermatitis, 'zero therapy' is the treatment of choice, which involves discontinuing possible exacerbants such as cosmetics and topical corticosteroids 2, 5
• Topical metronidazole, erythromycin, and pimecrolimus are effective treatment choices for moderate disease 2, 3, 5
• Oral tetracycline is the best validated choice for more severe cases, and systemic isotretinoin should be considered as a therapeutic option for patients refractory to all standard therapies 2, 3
• Repairing the impaired skin barrier function is essential to minimize associated skin inflammation and sensitivity, which results in resolution of the objective and subjective symptoms 6