Can perioral dermatitis spread before it gets better?

Management of Perioral Dermatitis

Yes, perioral dermatitis can spread before it gets better, especially during the initial treatment phase when discontinuing topical corticosteroids that may have triggered the condition.

Understanding Perioral Dermatitis Progression

• Perioral dermatitis is a common acneiform facial eruption affecting both adults and children, with variants including periorificial and granulomatous periorificial dermatitis 1
• The condition typically presents as papulovesicular eruptions in the perioral region with a characteristic narrow spared zone around the edge of the lips 2
• When discontinuing topical corticosteroids (a common trigger), patients often experience a "rebound phenomenon" where the condition temporarily worsens before improving 2

Common Triggers and Exacerbating Factors

• Topical corticosteroid use on the face commonly precedes the manifestation of perioral dermatitis 1, 3
• Other potential triggers include:
  • Cosmetics, sunscreens, and fragrances 4
  • Fluoridated toothpaste (in some cases) 5
  • Various skin irritants and physical factors that disrupt the epidermal barrier 2

Treatment Approach

First-Line Management

• Complete avoidance of triggering irritants or allergens is essential 4
• "Zero therapy" (discontinuation of all topical products) is the treatment of choice for mild forms of perioral dermatitis 2, 6
• Use gentle cleansers and soap substitutes instead of harsh soaps 4
• Apply moisturizers immediately after washing to repair the skin barrier 4

Medication Options

• For moderate disease, treatment includes:
  • Topical metronidazole 1, 3
  • Topical erythromycin 1, 6
  • Topical pimecrolimus (particularly effective if prior corticosteroid use has occurred) 1, 6
• For more severe cases:
  • Oral tetracycline in a subantimicrobial dose until complete remission is the best validated choice 1, 2
  • For children under 8 years old, oral erythromycin may be used instead of tetracyclines 3
  • Systemic isotretinoin should be considered for patients refractory to standard therapies 2

Managing the Spread During Treatment

• Close follow-up is recommended during the initial treatment period, especially for steroid-induced perioral dermatitis, as the rebound phenomenon typically develops after cessation of previous topical treatment 2
• A low-potency topical steroid may be used briefly to suppress inflammation and wean off stronger steroids, but this approach must be used with caution 3
• Continuous psychological support is important as the condition may temporarily worsen before improving 2

Prognosis and Expectations

• Most cases of perioral dermatitis are self-limited if possible exacerbants like cosmetics and topical corticosteroids are discontinued 6
• The condition typically waxes and wanes for weeks to months 3
• Complete resolution can be expected with proper treatment and avoidance of triggers 4

Common Pitfalls to Avoid

• Overuse of topical corticosteroids on the face can lead to skin thinning, telangiectasia, and worsening of perioral dermatitis 4
• Failure to identify and completely avoid the causative agent will result in persistent dermatitis 4
• Using very hot water for washing can exacerbate the condition 4
• Over-reliance on barrier creams may give a false sense of security 4