Adult with a perinasal rash and no significant medical history—what are the likely causes and appropriate treatment?

Perinasal Rash in Adults: Diagnosis and Management

Most Likely Diagnoses

The most common causes of perinasal rash in an otherwise healthy adult are seborrheic dermatitis, rosacea, perioral dermatitis (especially if using intranasal corticosteroids), and allergic contact dermatitis. 1, 2, 3

Seborrheic Dermatitis

• Presents with erythematous, scaly patches in sebum-rich areas including the nasolabial folds, eyebrows, and scalp 1
• Affects 1-3% of immunocompetent adults, more common in men 1
• Associated with Malassezia yeast overgrowth and abnormal immune responses to these organisms 1
• May coexist with blepharitis, rosacea, or acne vulgaris 1

Rosacea

• Characterized by persistent erythema, flushing, papules, pustules, and telangiectasias primarily affecting the malar and nasal areas 2
• Most common between ages 30-60, more frequent in women but more severe in men 2
• Fair-skinned individuals of Northern European descent are at highest risk 2
• Ocular involvement occurs commonly, including blepharitis (most common), conjunctivitis, burning, and grittiness 2, 4
• Distribution of papulopustular lesions with telangiectasia and flushing distinguishes rosacea from other facial eruptions 4

Perioral Dermatitis (Drug-Induced)

• Small erythematous papules, papulovesicles, and papulopustules on a background of redness, beginning in nasolabial areas and spreading to perioral zone 3
• Strongly associated with intranasal corticosteroid use in patients with allergic rhinitis 3
• Commonly misdiagnosed as contact or seborrheic dermatitis, leading to inappropriate topical steroid treatment that worsens the condition 3

Allergic Rhinitis with Perinasal Irritation

• Pale or bluish nasal mucosa with clear rhinorrhea, nasal itching, and sneezing 5
• Frequent nose rubbing ("allergic salute") can cause perinasal skin irritation 5
• May present with "allergic shiners" (dark circles under eyes) from venous congestion 5

Diagnostic Approach

Key History Elements

• Duration and pattern of symptoms (acute vs. chronic, seasonal vs. perennial) 5
• Medication history, specifically intranasal corticosteroid use 3
• Triggers: sun exposure, spicy foods, alcohol, temperature extremes (suggests rosacea) 2
• Associated symptoms: nasal congestion, itching, sneezing (suggests allergic component) 5
• Ocular symptoms: burning, grittiness, blepharitis (suggests rosacea or allergic rhinitis) 2, 5
• Personal or family history of atopy 5

Physical Examination Findings

• Seborrheic dermatitis: greasy, yellowish scales in nasolabial folds, eyebrows, scalp 1
• Rosacea: central facial erythema, telangiectasias, papules/pustules without comedones, possible rhinophyma 2
• Perioral dermatitis: papules and pustules sparing the vermillion border, background erythema 3
• Allergic rhinitis: pale/bluish nasal mucosa, clear discharge, conjunctival injection 5

Treatment Recommendations

For Seborrheic Dermatitis

Topical antifungal agents are preferred over corticosteroids as first-line therapy because they avoid the risk of skin atrophy and telangiectasia with prolonged use. 1

• Topical antifungals (ketoconazole, ciclopirox) in cream or shampoo formulations 1
• Reserve topical corticosteroids for short-term use during acute flares only 1
• For severe or refractory cases, consider oral antifungals: 6
  • Itraconazole 200 mg/day for first week of month, then 200 mg/day for first 2 days monthly for 2-11 months 6
  • Terbinafine 250 mg/day continuously for 4-6 weeks or intermittently (12 days/month) for 3 months 6
  • Fluconazole 50 mg/day for 2 weeks or 200-300 mg weekly for 2-4 weeks 6

For Rosacea

Systemic tetracycline antibiotics combined with topical metronidazole achieve remission in most cases. 2

• Oral tetracycline, doxycycline, or minocycline for anti-inflammatory effects 2
• Topical metronidazole gel or cream 2
• Patient education on trigger avoidance (alcohol, spicy foods, temperature extremes, stress) 2
• Refer to ophthalmology if significant ocular involvement 2

For Perioral Dermatitis

Immediately discontinue intranasal corticosteroids if being used. 3

• Stop all topical corticosteroids (these worsen the condition) 3
• Oral tetracycline-class antibiotics 3
• Topical metronidazole or erythromycin 3

For Allergic Rhinitis Component

• Intranasal corticosteroids are the most effective single-agent therapy for allergic rhinitis 7
• Second-generation oral antihistamines (cetirizine, loratadine) for rhinorrhea and sneezing 7
• Intranasal saline irrigation for symptomatic relief 7
• Allergen avoidance based on specific IgE testing 7

Critical Pitfalls to Avoid

• Do not use topical corticosteroids for perioral dermatitis—they worsen the condition and delay healing 3
• Do not assume colored nasal discharge indicates bacterial infection; it can occur in viral URI or allergic rhinitis 5
• Do not overlook intranasal steroid use as a cause of perinasal dermatitis 3
• Do not miss ocular involvement in rosacea, which requires ophthalmology referral 2
• Recognize that multiple conditions may coexist (e.g., seborrheic dermatitis with rosacea or allergic rhinitis) 1

When to Refer

• Severe or refractory cases not responding to first-line therapy 1, 2
• Significant ocular involvement suggesting rosacea 2
• Diagnostic uncertainty requiring skin biopsy or patch testing 1
• Need for allergy testing to guide allergen avoidance 7