What is the treatment for perioral and periocular dermatitis?

Treatment of Perioral and Periocular Dermatitis

The first-line treatment for perioral and periocular dermatitis is to discontinue all topical corticosteroids and potential irritants, followed by topical erythromycin 2% applied as a thin film to affected areas once or twice daily. 1

Initial Management

• Remove all potential irritants including cosmetics, facial soaps, fluorinated toothpastes, and other skincare products that may exacerbate the condition 2
• Use gentle, non-irritating soap substitutes for cleansing and apply emollients regularly to maintain skin hydration and repair the skin barrier 2
• Implement "zero therapy" (avoiding all topical products) as the treatment of choice for mild forms of perioral dermatitis 3
• Strictly avoid topical corticosteroids as they are a common trigger for perioral dermatitis and can lead to rebound phenomenon when discontinued 1, 2

Topical Treatments

• Apply topical erythromycin 2% as a thin film to affected areas once or twice daily for mild to moderate cases 1
• Consider topical metronidazole as an alternative treatment option, particularly in children, though evidence suggests it may be less effective than oral tetracyclines 4, 5
• Topical pimecrolimus can rapidly reduce disease severity, especially in cases with prior corticosteroid use, though it may not decrease time to complete resolution 4

Practical Considerations for Topical Treatments

• Monitor for common side effects of topical erythromycin including dryness, irritation, and mild burning sensation upon application 1
• Reduce frequency of application or use only one topical medication if excessive dryness occurs 1
• Avoid concurrent use of topical erythromycin with alcohol-containing cosmetics, medicated soaps, or abrasive agents as these may increase irritation 1
• Be aware that topical erythromycin may induce bacterial resistance when used as monotherapy 1

Systemic Treatments

• For moderate to severe cases, oral tetracycline in a subantimicrobial dose is the best validated choice until complete remission is achieved 3, 4
• In children under 8 years old where tetracyclines are contraindicated, oral erythromycin is an appropriate alternative 6, 7
• Consider systemic isotretinoin only for patients refractory to all standard therapies 3

Special Populations

• For periocular dermatitis, exercise caution with topical treatments to avoid getting medication in the eye 8
• For pregnant patients, topical erythromycin (pregnancy category B) is relatively safe 1
• In children, topical metronidazole is commonly used, though evidence supporting its efficacy is relatively weak compared to other options 6, 7, 4

Treatment Algorithm

1. First step: Discontinue all topical corticosteroids and potential irritants
2. Mild cases:
   • Zero therapy (no products) 3
   • Topical erythromycin 2% once or twice daily 1
3. Moderate cases:
   • Topical erythromycin or metronidazole 1, 4
   • Consider topical pimecrolimus, especially for steroid-induced cases 4
4. Severe cases:
   • Oral tetracycline (adults and children >8 years) 3, 4
   • Oral erythromycin (children <8 years) 6, 7
5. Refractory cases:
   • Consider systemic isotretinoin 3

Common Pitfalls to Avoid

• Using topical corticosteroids to treat perioral dermatitis, as they provide only temporary relief but worsen the condition long-term 1, 2
• Failing to provide adequate patient education about the rebound phenomenon that typically occurs after discontinuing topical corticosteroids 3
• Not identifying and eliminating potential irritants that may be contributing to the condition 2
• Overlooking bacterial antibiotic susceptibility profiling for recurrent or non-responsive cases 1