What is the treatment for perioral dermatitis?

Treatment for Perioral Dermatitis

The first-line treatment for perioral dermatitis is discontinuation of topical corticosteroids ("zero therapy") followed by oral tetracyclines for adults or topical metronidazole for children, as these approaches have shown the strongest evidence for reducing time to resolution and improving symptoms. 1, 2, 3

Understanding Perioral Dermatitis

Perioral dermatitis is an acneiform facial eruption characterized by:

• Erythematous papules, pustules, and papulovesicles
• Typically distributed around the mouth (perioral), nose (perinasal), or eyes (periorbital)
• More common in young women, but can affect both children and adults
• Often preceded by topical corticosteroid use on the face

Treatment Algorithm

Step 1: Discontinue Potential Triggers

• Stop all topical corticosteroids (most important step)
• Avoid potential irritants:
  • Fluorinated toothpastes
  • Heavy facial moisturizers
  • Cosmetics with occlusive properties 1, 2

Step 2: First-Line Treatments

For Adults:

• Oral tetracyclines (first choice):
  • Tetracycline 250-500 mg twice daily for 4-8 weeks
  • Doxycycline 100 mg once or twice daily for 4-8 weeks
  • Minocycline 100 mg once or twice daily for 4-8 weeks 2, 3

For Children (under 8 years):

• Topical metronidazole 0.75-1% cream or gel applied twice daily for 4-8 weeks 4, 5
• Topical erythromycin 2% applied twice daily for 4-8 weeks 2
• Oral erythromycin (if severe) 30-50 mg/kg/day divided into 2-4 doses 4

Step 3: Alternative or Adjunctive Treatments

• Topical pimecrolimus 1% cream (especially if rebound inflammation after steroid withdrawal) 2
• Topical azelaic acid 15-20% cream or gel twice daily 5
• Adapalene 0.1% gel once daily (for maintenance) 5

Step 4: For Refractory Cases

• Oral isotretinoin at low doses (0.2-0.3 mg/kg/day) for 4-6 months in severe or resistant cases 5

Special Considerations

Steroid Withdrawal

• Patients may experience worsening of symptoms when discontinuing topical steroids
• Management options:
  1. Cold compresses for symptomatic relief
  2. Topical pimecrolimus to reduce rebound inflammation 2
  3. In severe cases, a brief tapering course using a low-potency topical steroid while initiating other therapies 4

Pediatric Patients

• Oral tetracyclines are contraindicated in children under 8 years due to risk of dental staining
• Topical treatments (metronidazole, erythromycin) are preferred first-line options
• Oral erythromycin is the systemic antibiotic of choice if needed 4

Duration of Treatment and Follow-up

• Most treatments require 4-8 weeks for complete resolution
• Follow-up at 2-4 weeks to assess response
• Continue treatment for 1-2 weeks after clinical resolution to prevent relapse

Common Pitfalls to Avoid

1. Continuing topical corticosteroid use (can perpetuate the condition)
2. Using occlusive cosmetics or heavy moisturizers during treatment
3. Stopping treatment too early (before complete resolution)
4. Using topical steroids to manage rebound inflammation (may provide temporary relief but worsens condition long-term) 6
5. Failure to identify and address underlying triggers

Perioral dermatitis is typically self-limiting if exacerbating factors are removed, but appropriate treatment significantly reduces the time to resolution and improves patient quality of life.