What are the management options for perioral dermatitis, herpes simplex, and bullous impetigo?

Management of Perioral Dermatitis, Herpes Simplex, and Bullous Impetigo

Perioral Dermatitis

For perioral dermatitis, discontinue all topical corticosteroids immediately and initiate oral tetracycline as first-line therapy, which provides the strongest evidence for rapid resolution. 1, 2

Initial Management Approach

• "Zero therapy" is the foundation: Stop all topical corticosteroids, cosmetics, and facial irritants immediately, as most cases are self-limited once exacerbating factors are removed 2, 3
• Warn patients about rebound phenomenon: Expect temporary worsening for 1-2 weeks after stopping topical steroids, particularly with fluorinated corticosteroids - close follow-up during this period is essential 3, 4

Pharmacologic Treatment by Severity

Mild disease:

• Topical metronidazole or topical erythromycin can be used, though evidence is weaker than for oral therapy 2, 3
• Topical pimecrolimus rapidly reduces disease severity, particularly beneficial in steroid-induced cases, though it doesn't shorten time to complete resolution 2, 3

Moderate to severe disease:

• Oral tetracycline is the gold standard with the strongest evidence for significantly shortening time to papule resolution 1, 2
• Use subantimicrobial doses until complete remission is achieved 3
• Topical erythromycin reduces resolution time but not as rapidly as oral tetracyclines 2

Pediatric Considerations

• For children under 8 years old: Avoid tetracyclines due to dental staining risk 1
• Use topical metronidazole alone or combined with oral erythromycin instead 4
• Boys and girls are equally affected in the prepubertal period, with median age in prepubertal years 4
• Inhaled corticosteroids can trigger perioral dermatitis - consider discontinuation if temporal association exists 5

Refractory Cases

• Systemic isotretinoin should be considered for patients refractory to all standard therapies 3

---

Herpes Simplex

For herpes simplex infections, initiate antiviral therapy with famciclovir or equivalent at the first sign of recurrence to minimize morbidity and transmission risk. 6

Clinical Recognition

• Characteristic presentation: Grouped, punched-out erosions or vesiculation distinguish herpes simplex from bacterial infections 7
• Deterioration in stable skin conditions may indicate secondary viral infection requiring swabs 7

Treatment Regimens (FDA-Approved)

Immunocompetent adults: 6

• Herpes labialis (cold sores): Famciclovir 1500 mg as a single dose
• Recurrent genital herpes treatment: Famciclovir 1000 mg twice daily for 1 day
• Suppressive therapy for genital herpes: Famciclovir 250 mg twice daily

HIV-infected adults: 6

• Recurrent orolabial or genital herpes: Famciclovir 500 mg twice daily for 7 days

Important Limitations and Monitoring

• Renal dose adjustment required: Reduce dosage based on creatinine clearance to prevent acute renal failure, particularly in patients with underlying renal disease 6
• Efficacy not established for first episode genital herpes, ophthalmic zoster, or immunocompromised patients (except HIV-infected with recurrent orolabial/genital herpes) 6
• Monitor for drug interactions with probenecid, which may increase penciclovir levels and toxicity 6

---

Bullous Impetigo

For bullous impetigo, apply topical mupirocin 2% ointment as first-line therapy for localized disease caused by Staphylococcus aureus and Streptococcus pyogenes. 8

Topical Management

• Mupirocin ointment 2% is FDA-indicated specifically for impetigo treatment 8
• Apply to affected areas as directed for localized disease 8

Infection Control Principles

• Daily washing with antibacterial products decreases colonization and reduces infection risk 7
• Use aseptic technique for any wound care 7
• Vigilance for signs of spreading infection is essential, as infection increases scarring risk 7

When to Escalate to Systemic Therapy

• Systemic antibiotics indicated when: Local or systemic signs of infection develop, or infection extends beyond initial site 7
• Send bacterial swabs from erosions showing clinical signs of infection before initiating systemic therapy 7
• Follow local antibiotic policy for agent selection 7

Blister Management (if bullae present)

• Pierce blisters at the base with sterile needle (bevel up) to facilitate gravity drainage 7
• Never deroof the blister - leave roof intact as biological dressing 7
• Cleanse gently with antimicrobial solution before and after drainage 7
• Apply nonadherent dressing if necessary 7

Common Pitfall

• Avoid topical antimicrobials for prolonged periods - use only for short durations to prevent resistance 7