Perioral Dermatitis

Synonyms

Perioral dermatitis; Rosacea-like dermatitis.

Epidemiology

In the USA around 0.5 to 1%, no clear data from Europe. Often misdiagnosed.

Definition

Acneiform dermatosis with small papules and tiny pustules without comedones and with almost exclusively perioral and periorbital involvement. F 70% > 30% M. 20-40 years of age. Increasing number of children and adolescents.

Aetiology & Pathogenesis

Some evidence exists that a hyperhydration of the follicular epithelium and steroid induced atrophy of the epithelium can support the release of inflammatory mediators into the surrounding superficial dermis and acroinfundibulum.

Long-term use of topical steroid preparations
Daily cosmetics: skin care with high water content ointments and creams incl.sunscreens and fluorinated toothpastes
Physical factors: high humidity
Microbiologic factors: Fusiform spirilla bacteria from the oral microbiome settling in the perioral region. Often induction or worsening after long lasting dental procedures, Malassezia furfur and Candida species can superinfect.

Signs & Symptoms

Inflammatory small papules with tiny pustules, erythema and small scales are dominant lesions. The patients often complain of burning and tight sensation. No comedones.

Localisation

Perioral, periorbital, nasolabial, glabella. Genital.

Laboratory & other workups

Not necessary. Sometimes bacterial and mycologic swab.

Dermatopathology

Usually not necessary. In granuloma like lesions a biopsy to exclude rosacea, acne agminata or sarcoidosis and histiocytic diseases can become necessary. Mostly perifollicular and dermal edema and prominent lymphomononuclear infiltrates with slight spongiosis of the acroinfundibular and interfollicular sometimes acanthotic epithelium.

Course

It mostly starts slowly over 2- 3 weeks. Flares can be seen whilst reducing frequency of application of corticosteroid creams.

Complications

Granulomatous type of POD.

Diagnosis

Sometimes difficult. Case history and localisation important. Exclude comedones and rosacea.

Differential diagnosis

Rosacea of papulo-pustular type. Gram-negative folliculitis. Corticosteroid acne, PRIDE syndrome from oncologic therapy with EGF receptor antagonists.

Prevention & Therapy

Topical: withdraw corticosteroids, however, flare up may occur. Initially slow down corticosteroids to every other day or every third day. Change from strong moisturizer galenics to less water containing ones. Apply initially over night drying zinc lotion. Metronidazole lotion, fucidin cream, topical ketoconazole help to reduce spirilla microbes. Systemic: low dose doxycycline (anti-inflammatory, not for antibiotic effects).

Important point: never use topical corticosteroids as first treatment.

4.1.3 Perioral Dermatitis