Perioral Dermatitis in a 3-Year-Old with Idiopathic Urticaria
The most likely diagnosis is perioral dermatitis, and treatment should begin with immediate discontinuation of any topical corticosteroids (including those used for urticaria management), followed by topical metronidazole with or without oral erythromycin, while maintaining gentle emollient therapy for the underlying dry skin. 1
Diagnosis: Perioral Dermatitis
The clinical presentation of a peri-oral dry skin rash in a young child strongly suggests perioral dermatitis, which presents with:
- Flesh-colored or erythematous inflamed papules, micronodules, and rare pustules distributed around the mouth (perioral), nose (perinasal), or eyes (periorbital) 1
- Absence of systemic symptoms with variable pruritus 1
- Age range typically 7 months to 13 years (median in prepubertal period), affecting boys and girls equally 1
Key Diagnostic Consideration
Perioral dermatitis in children is likely triggered by topical fluorinated corticosteroids or other facial products (including physical sunscreens with micropigments in children with dry skin). 1, 2 Given this child's history of idiopathic urticaria, there may have been prior topical corticosteroid use that precipitated the perioral rash.
Treatment Algorithm
Step 1: Immediate Discontinuation
- Stop all topical fluorinated corticosteroids on the face immediately 1
- Discontinue any physical sunscreens containing micropigments, as these are known triggers in children with dry skin 2
Step 2: Primary Treatment
- Topical metronidazole as first-line therapy 1
- Add oral erythromycin for more extensive or resistant cases (tetracyclines are contraindicated in this age group) 1
- Consider low-potency topical corticosteroid briefly (such as hydrocortisone) only to suppress inflammation during the weaning period from stronger steroids, if previously used 1
Step 3: Supportive Skin Care
- Apply emollients liberally and frequently (at least twice daily) to address the underlying dry skin and prevent dehydration of the stratum corneum 3
- Avoid hot water and excessive soap use; substitute with dispersible cream as a soap alternative 3
Step 4: Concurrent Urticaria Management
For the underlying idiopathic urticaria:
- Continue non-sedating H1 antihistamines (desloratadine, fexofenadine, levocetirizine) as first-line treatment 4
- Avoid topical corticosteroids on facial areas to prevent worsening of perioral dermatitis 1
- Short courses of oral corticosteroids (<7 days) may be used for severe urticaria exacerbations if clinically necessary, but long-term use is contraindicated 5
Critical Pitfalls to Avoid
Do not continue topical corticosteroids on the face, as this will perpetuate and worsen perioral dermatitis despite treating the urticaria. 1 The condition waxes and wanes for weeks to months, and continued steroid use delays resolution.
Do not overlook secondary bacterial infection, which commonly complicates both eczematous conditions and perioral dermatitis, presenting with crusting or weeping that requires flucloxacillin treatment. 3, 6
Do not use physical sunscreens with micropigments in children with dry skin, as they are a recognized trigger for perioral dermatitis in this population. 2
Expected Course
Perioral dermatitis typically waxes and wanes for weeks to months but responds well to the treatment regimen outlined above. 1 The condition is histologically indistinguishable from rosacea and represents a probable juvenile form of this disorder. 1
The underlying idiopathic urticaria has a 30-55% spontaneous resolution rate within 5 years in chronic cases, though acute episodic urticaria (most common in pediatrics) is usually self-limiting. 4, 7