How should perioral skin breakdown and erythema be treated in a pediatric patient with a self‑scraping (teeth‑scraping) habit?

Treatment of Perioral Skin Breakdown and Erythema from Teeth-Scraping Behavior in Pediatric Patients

Apply white soft paraffin ointment every 2 hours to the affected perioral skin to prevent drying, promote healing, and create a protective barrier against ongoing mechanical trauma from the teeth-scraping behavior. 1

Initial Assessment

Before initiating treatment, evaluate for complications that would alter management:

• Check for signs of bacterial infection including crusting, weeping, purulent discharge, or honey-colored exudate, which commonly indicates Staphylococcus aureus colonization 1
• Look for grouped vesicles or punched-out erosions that suggest herpes simplex infection requiring virological screening and antiviral therapy 1
• Assess for underlying atopic dermatitis by examining for dry skin elsewhere, flexural involvement, or personal/family history of atopy 1

Primary Treatment Protocol

For Simple Erosions Without Infection

Barrier protection is the cornerstone of management:

• Apply white soft paraffin ointment every 2 hours during waking hours to maintain continuous barrier protection against saliva, friction, and ongoing mechanical trauma 1, 2
• Clean the area once daily with warm saline using a soft cloth or oral sponge to remove debris without causing additional trauma 1, 3
• Avoid all soaps and detergents on the perioral area as they strip natural lipids and worsen barrier dysfunction 1

If Atopic Dermatitis is Present

The treatment approach must be modified:

• Apply emollients 3-8 times daily to decrease transepidermal water loss, which is particularly important given the mechanical trauma 1
• Use topical corticosteroids as the mainstay for active eczematous inflammation, though this must be balanced against the risk of perioral dermatitis from corticosteroid use 1, 4
• Consider clobetasol propionate 0.05% cream or ointment applied topically to affected lip areas if severe inflammation is present 3

If Infection is Present

Modify the approach when infection complicates the clinical picture:

• Use aqueous chlorhexidine 0.05% as an antiseptic on erosive lesions to reduce bacterial colonization 1, 3
• Apply topical erythromycin if bacterial infection is confirmed, as it reduces time to resolution 5, 4
• Avoid occlusive ointments when active infection is present as they may increase infection risk and impair sweating 1

Behavioral Intervention Considerations

While addressing the skin breakdown, the underlying teeth-scraping behavior requires parallel management:

• Consider dental referral for evaluation of oral habits that may require intervention to prevent ongoing trauma 6
• Maintain continuous barrier protection even between episodes of scraping to allow healing and prevent worsening 1, 2

Critical Pitfalls to Avoid

Never use adhesive dressings on or near the lips as they cause significant additional trauma upon removal, worsening the existing breakdown 1, 2

Avoid topical anesthetics for perioral use in young children due to accidental ingestion risk 1, 2

Do not apply topical corticosteroids if there is any suspicion this could be perioral dermatitis, as corticosteroid use is the most common causative factor and will worsen the condition despite initial improvement 4, 7

Never allow the area to remain dry between applications, as the mechanical trauma from teeth-scraping combined with barrier dysfunction creates a cycle of worsening breakdown 8

Monitoring and Red Flags

Reassess within 24-48 hours and instruct caregivers to watch for:

• Increasing pain, redness, or swelling beyond 48 hours requiring urgent reassessment for infection 1, 2
• Purulent discharge or fever indicating systemic infection 1, 2
• Grouped vesicles or new erosions suggesting herpes simplex requiring antiviral therapy 1
• Difficulty eating or drinking due to worsening pain 1, 2

Special Considerations for Refractory Cases

If the skin breakdown does not improve with barrier protection alone:

• Consider topical pimecrolimus as it rapidly reduces severity of perioral inflammation without the risks of corticosteroids, particularly if prior corticosteroid use has occurred 5, 4
• Topical metronidazole can be considered in children, though evidence is weaker than for other options 5, 4
• Refer to pediatric dermatology if no improvement occurs within 1-2 weeks of appropriate barrier therapy 1

The key principle is maintaining continuous barrier protection with frequent white soft paraffin application while addressing any infectious or inflammatory complications that arise from the ongoing mechanical trauma.