Treatment of Perioral Dermatitis
The first-line treatment for perioral dermatitis is immediate discontinuation of all topical corticosteroids and potential irritants ("zero therapy"), followed by topical erythromycin 2% applied once or twice daily to affected areas. 1
Initial Management: Zero Therapy
Immediately discontinue all topical corticosteroids, as they are a primary trigger for perioral dermatitis and cause rebound worsening when stopped, despite providing temporary improvement. 1, 2
Remove all potential irritants from the patient's routine: 1, 2
- Cosmetics and facial makeup
- Facial soaps and cleansers
- Fluorinated toothpastes
- Other skincare products including greasy creams
Implement gentle skin care: 1
- Use non-irritating soap substitutes for cleansing
- Apply emollients regularly to maintain skin hydration and repair the skin barrier
- Avoid manipulation of skin lesions due to infection risk 3
Important caveat: Patients with steroid-induced perioral dermatitis will likely experience a rebound phenomenon after stopping topical corticosteroids and require close follow-up during this initial period. 4
Topical Pharmacologic Treatment
Apply topical erythromycin 2% as a thin film to affected areas once or twice daily for mild to moderate cases. 1 This is supported by strong evidence showing it reduces time to resolution, though not as rapidly as oral tetracyclines. 5
Monitor for common side effects: 1
- Dryness
- Irritation
- Mild burning sensation upon application
If excessive dryness occurs, reduce frequency of application or use only one topical medication. 1
Avoid concurrent use with: 1
- Alcohol-containing cosmetics
- Medicated soaps
- Abrasive agents (these increase irritation)
Alternative topical options with evidence:
- Topical metronidazole (though evidence is weaker than erythromycin and inferior to oral tetracycline) 5, 6, 7
- Topical pimecrolimus (rapidly reduces disease severity, particularly useful if prior corticosteroid use occurred, though doesn't decrease time to complete resolution) 5, 6
Systemic Treatment for Moderate to Severe Cases
For moderate to severe perioral dermatitis, oral tetracycline is the best validated choice with the strongest evidence, significantly shortening time to papule resolution. 5, 4, 6
Dosing approach: 4
- Use subantimicrobial doses
- Continue until complete remission is achieved
For children under 8 years old, oral tetracycline is contraindicated due to tooth discoloration risk. 6 In this population, consider:
For refractory cases, systemic isotretinoin should be considered as a therapeutic option for patients who fail all standard therapies. 4
Special Populations
Pregnant patients: Topical erythromycin (pregnancy category B) is relatively safe. 1
Periocular dermatitis: Exercise caution with topical treatments to avoid getting medication in the eye. 1
Children: The condition equally affects boys and girls, with median age in the prepubertal period, and may represent a juvenile form of rosacea. 8
Common Pitfalls to Avoid
Never use topical corticosteroids as maintenance therapy, even though they provide temporary relief—they worsen the condition long-term and cause rebound phenomenon. 9, 3, 2
Do not use greasy creams for basic care, as their occlusive properties facilitate folliculitis development. 3, 2
Avoid topical antibiotics like neomycin and bacitracin, which can cause allergic contact dermatitis themselves. 3
Do not overlook bacterial antibiotic susceptibility profiling for recurrent or non-responsive cases. 1
Be aware that topical erythromycin may induce bacterial resistance when used as monotherapy. 1
Expected Course
Most cases of perioral dermatitis are self-limited if exacerbants (cosmetics and topical corticosteroids) are discontinued. 5 The disease typically waxes and wanes for weeks to months. 8 Oral tetracyclines significantly shorten this natural course, while topical erythromycin also reduces time to resolution but less rapidly. 5