What is the treatment for perioral dermatitis?

Treatment of Perioral Dermatitis

The first-line treatment for perioral dermatitis includes discontinuation of topical corticosteroids, implementation of "zero therapy," and oral tetracyclines for adults or topical metronidazole for children. 1, 2, 3

Etiology and Pathogenesis

• Perioral dermatitis is a common acneiform facial eruption affecting both adults and children, with topical corticosteroid use frequently preceding its manifestation 1
• The condition primarily affects women aged 15-45 years in its classic form, while the granulomatous variant is more common in prepubescent boys 2
• Epidermal barrier dysfunction is considered the main underlying pathogenic factor 2

First-Line Treatment Approach

Discontinuation of Potential Triggers

• Immediately discontinue topical corticosteroids, which are often implicated in causing or exacerbating perioral dermatitis 2, 3
• Avoid potential irritants including greasy creams, which might facilitate the development of folliculitis due to their occlusive properties 4
• Eliminate cosmetics and other facial products that may be contributing to the condition 3

"Zero Therapy"

• Many cases are self-limited if potential exacerbants like cosmetics and topical corticosteroids are discontinued (known as "zero therapy") 3
• This approach may be sufficient for mild cases but requires patient education and psychological support due to potential initial worsening 2
• Be aware of the rebound phenomenon that commonly develops after cessation of previous topical corticosteroid treatment 2

Pharmacological Treatment

• For moderate to severe cases in adults, oral tetracyclines in subantimicrobial doses until complete remission are the best validated treatment option 1, 2, 3
• For children under 8 years (who cannot take tetracyclines) and milder cases, topical metronidazole is the preferred treatment 1, 5
• Topical erythromycin and pimecrolimus are also effective treatment choices with good supporting evidence 1, 3

Treatment Algorithm

For Mild Cases

1. Discontinue all topical corticosteroids and potential irritants 2, 3
2. Implement "zero therapy" - using only gentle, non-irritating cleansers and avoiding all cosmetics 3
3. Apply hypoallergenic moisturizing creams if skin is dry 4
4. Monitor for 2-4 weeks to assess response 2

For Moderate Cases

1. All steps for mild cases plus:
2. Add topical therapy:
   • Adults and children: Topical metronidazole or erythromycin 1, 3
   • For steroid-induced cases: Consider topical pimecrolimus which rapidly reduces disease severity 3

For Severe Cases

1. All steps for mild cases plus:
2. Adults: Oral tetracycline until complete remission 2, 3
3. Children under 8 years: Topical metronidazole or erythromycin 1, 5
4. Children over 8 years: Consider oral tetracyclines at appropriate dosing 1
5. For refractory cases: Consider systemic isotretinoin 2

Special Considerations

• Avoid topical antibiotics like neomycin and bacitracin as they can cause allergic contact dermatitis themselves 6
• β-lactam antibiotics might be useful in cases where tetracyclines cannot be used, especially when fusobacteria are present 7
• For perioral dermatitis with significant inflammation after steroid withdrawal, a short course of low-potency topical steroid may be used to suppress inflammation while weaning off stronger steroids 5
• The condition typically waxes and wanes for weeks to months, requiring patient education about the chronic nature of the disease 2, 5

Pitfalls to Avoid

• Avoid topical steroids as maintenance therapy as they can worsen the condition long-term, even though they may provide temporary improvement 4, 2
• Do not apply greasy creams for basic care as they might facilitate the development of folliculitis due to their occlusive properties 4
• Avoid manipulation of skin lesions due to risk of infection 4
• Be aware that topical retinoids may be irritating and systemic retinoids may aggravate xerosis and increase itch sensation 4