What is the diagnosis and treatment for a child with a spotted, raised papular rash around the mouth without fever?

Perioral Dermatitis (Most Likely Diagnosis)

The clinical presentation of a spotted, raised papular rash around the mouth in a child without fever is most consistent with perioral dermatitis, which should be treated by discontinuing any topical corticosteroids and initiating topical metronidazole or oral erythromycin depending on severity. 1

Clinical Features Supporting This Diagnosis

• Absence of systemic symptoms (no fever) is characteristic of perioral dermatitis 1
• Periorificial distribution (around the mouth) with flesh-colored or erythematous papules is the hallmark presentation 1
• This condition affects children from 7 months to 13 years, with equal distribution between boys and girls 1
• The disease typically waxes and wanes for weeks to months 1

Critical Differential Diagnoses to Exclude

Before confirming perioral dermatitis, you must rule out more serious conditions:

Impetigo (Bacterial Infection)

• Look for honey-crusted lesions or pustules that rupture and form golden crusts 2
• This is a superficial bacterial infection most commonly affecting the face 3
• If suspected, treat with topical mupirocin ointment three times daily for 8-12 days 2

Roseola (If Fever History Present)

• Critical distinction: Roseola presents with 3-4 days of high fever FOLLOWED by rash that appears when fever breaks 4
• Since your patient has no fever, roseola is unlikely 4
• Roseola affects children 6 months to 2 years primarily 4

Life-Threatening Conditions (Red Flags)

You must immediately exclude these if ANY of the following are present:

• Petechial rash pattern (non-blanching pinpoint lesions) suggests meningococcemia or Rocky Mountain Spotted Fever 5
• Systemic toxicity (fever, altered mental status, hypotension) requires immediate hospitalization 5
• Involvement of palms and soles suggests serious rickettsial or bacterial infection 6, 5
• Progressive clinical deterioration or rapidly spreading rash 5

Treatment Algorithm for Perioral Dermatitis

Step 1: Discontinue Aggravating Factors

• Immediately stop any topical fluorinated corticosteroids if being used on the face 1
• This is often the inciting factor in children 1

Step 2: Initiate Appropriate Therapy

For Mild Cases:

• Topical metronidazole alone applied to affected areas 1

For Moderate to Severe Cases:

• Topical metronidazole PLUS oral erythromycin (for younger children who cannot take tetracyclines) 1
• Oral tetracycline can be used in children ≥8 years 1

For Steroid Withdrawal Flare:

• Low-potency topical steroid may be used temporarily to suppress inflammation and wean off strong steroids 1

Common Pitfalls to Avoid

• Do not continue topical corticosteroids thinking they will help—they perpetuate the condition 1
• Do not prescribe antibiotics empirically without considering the clinical presentation; perioral dermatitis is not primarily infectious 1
• Do not miss impetigo if honey-crusted lesions are present, as this requires different treatment 2, 3
• Do not dismiss fever history—if fever preceded the rash, consider viral exanthems like roseola or more serious conditions 4, 3

Expected Clinical Course

• The condition typically persists for weeks to months with waxing and waning severity 1
• Reassess within 3-5 days if no clinical improvement 2
• Perioral dermatitis in childhood is likely a juvenile form of rosacea 1