What is the recommended frequency and duration for topical erythromycin (Erythromycin) and Elidel (Pimecrolimus) for perioral dermatitis, and what size are the tubes?

Treatment Recommendations for Perioral Dermatitis

For perioral dermatitis, apply topical erythromycin twice daily and Elidel (pimecrolimus) twice daily to affected areas, with treatment duration of 4-8 weeks for erythromycin and up to 6 weeks for Elidel, though Elidel should be discontinued once symptoms resolve. 1, 2, 3, 4

Topical Erythromycin Dosing

• Frequency: Apply twice daily (morning and evening) to affected areas after washing skin with warm water and soap and patting dry 1
• Duration: Continue until complete remission is achieved, typically requiring several weeks of treatment 3
• Application technique: Apply as a thin film using applicator top; if fingertips are used, wash hands after application 1
• Adjustment: Drying and peeling may be controlled by reducing frequency of applications 1

Evidence supporting erythromycin: Topical erythromycin reduces time to resolution of perioral dermatitis, though not as rapidly as oral tetracyclines 4. A study demonstrated successful treatment using 1.5% erythromycin topical solution twice daily 5

Elidel (Pimecrolimus 1%) Dosing

• Frequency: Apply a thin layer twice daily to affected skin 2
• Duration: Continue until signs and symptoms (itch, rash, redness) resolve, but discontinue if symptoms persist beyond 6 weeks 2
• Important limitation: Continuous long-term use should be avoided; application should be limited to areas of involvement 2
• Contraindication: Do not use with occlusive dressings 2

Evidence supporting pimecrolimus: A randomized, double-blind, vehicle-controlled study of 40 patients showed pimecrolimus cream 1% was significantly more effective than vehicle (P = 0.005-0.02) during treatment, with 50% responder rates at week 2 6. Pimecrolimus rapidly reduces disease severity, particularly beneficial if prior corticosteroid use has occurred 4. However, it may not decrease time to complete resolution as effectively as oral tetracyclines 4

Treatment Algorithm

Initial approach:

• Discontinue all topical corticosteroids and cosmetics ("zero therapy") 3, 4
• For mild cases, zero therapy alone may be sufficient as most cases are self-limited 4

For moderate disease requiring active treatment:

• Start topical erythromycin twice daily 3, 4
• Consider adding pimecrolimus twice daily, especially if there is significant inflammation or prior steroid use 3, 4, 6
• Monitor closely for rebound phenomenon in first 2 weeks if patient was using topical steroids 3

Duration considerations:

• Reassess at 2 weeks for treatment response 6
• Continue erythromycin until complete remission 3
• Discontinue pimecrolimus when symptoms resolve or at 6 weeks maximum 2
• If no improvement by 6-8 weeks, consider oral tetracycline therapy 3, 4

Tube Sizes Available

Elidel (pimecrolimus) cream 1% is available in:

• 30 gram tubes
• 60 gram tubes
• 100 gram tubes 2

Note: Topical erythromycin tube sizes vary by manufacturer and formulation (solution, ointment, gel); specific sizes were not provided in the FDA labeling reviewed 1

Critical Caveats

• Rebound flare: Patients with steroid-induced perioral dermatitis require close follow-up as rebound phenomenon typically develops after cessation of topical corticosteroids 3
• Pediatric considerations: In children, topical metronidazole is frequently used, though evidence is weaker than for erythromycin 4. Pimecrolimus is approved for children ≥2 years for atopic dermatitis 7
• Storage: Store Elidel at 25°C (77°F); excursions permitted to 15-30°C (59-86°F); do not freeze 2
• Combination approach: Some evidence supports combining topical erythromycin with a low-potency topical steroid in a controlled, tapered regimen to prevent acute rebound flare 5