Case Study : Infection and Sepsis
25. Perioral Dermatitis
25. Erythematous rash on face
A 27-year-old Caucasian woman came into our clinic with an erythematous, papulopustular rash on her face. The small papules and pustules formed a confluence around her mouth and on her chin; the vermilion border was spared (FIGURE). The patient said that the rash started as a dry scaly patch on the corner of her mouth, and it spread over the course of a few weeks.
The patient had a history of eczema for which she used mometasone furoate cream. Initially, she thought the rash was a flare-up of her eczema, so she used her steroid cream. After using the cream on her face for a month, the patient reported that the rash continued to worsen and spread. She said that the rash was mildly itchy and that when she opened her mouth, it was moderately painful.
Diagnosis: Perioral dermatitis
Perioral dermatitis occurs in men and women of all ages and races, though it is more common in women between the ages of 16 and 45.(1,2).
Many agents have been implicated in the etiology of perioral dermatitis, including infectious pathogens, hormonal factors, and steroids.
Moisturizing creams and cosmetics, such as foundation and blush, can cause occlusion of skin follicles, leading to proliferation of skin flora and the resultant papulopustular rash seen in perioral dermatitis.(3).
In a similar manner, fluorinated corticosteroids enable opportunistic fusobacteria to become pathogenic, leading to the condition.
Other risk factors include premenstrual hormone changes, pregnancy, and the use of oral contraceptives, fluorinated toothpaste, inhaled steroids, or glucocorticoids.(4).
It’s easy to distinguish from these 3 conditions
The differential diagnosis includes contact dermatitis, atopic dermatitis, and rosacea.
Contact dermatitis is similar to perioral dermatitis in that the patient may indicate that she started using a new skin product. In most cases, the pruritus associated with contact dermatitis will aid in differentiating the 2 diagnoses.
Atopic dermatitis is more common in children and rarely has an adult onset. Often, there is a personal or family history of asthma or allergies. Distribution in adults is more typically on flexure surfaces, hands, and upper eyelids, and it is itchier than perioral dermatitis.
Rosacea is often associated with flushing, and is exacerbated by the ingestion of hot food and drinks, alcohol (red wine), and exposure to sun. The distribution is typically on the forehead, cheeks, nose, and around the eyes—rather than around the mouth.
A rash that’s painful and mildly itchy
Perioral dermatitis has distinct clinical features that distinguish it from other facial dermatoses.
The rash is classically described as tiny, dry, erythematous papulopustules in a pattern around the mouth, nasolabial folds, and chin, with sparing of the vermilion border.(1,2).
The clinical course is variable, but is often chronic, with flares.
Typically, the rash is only mildly pruritic, but a burning or painful sensation is common. Intolerance to sunlight, drying agents (such as soaps), or irritants (such as cosmetics) is also common.(3)
Treatment: Discontinue steroids, start antibiotics
If left untreated, perioral dermatitis rarely resolves on its own and will have a fluctuating course, punctuated by flares, that will last for years.
The prognosis is excellent, however, once appropriate therapy is instituted; recurrence after treatment is low.(5)
Cessation of topical steroids is a mainstay of treatment (6,7). (strength of recommendation [SOR]: B).
High-potency topical steroids can cause short-term improvement of the rash; removal will cause short-term worsening of symptoms.
It’s best, then, to switch your patient to a less potent steroid, and then gradually discontinue the steroid (3) (SOR: C).
Doing so can help the patient to avoid a rebound flare and the temptation to restart the steroid for short-term relief.
It’s also a good idea to tell the patient to stop using other causative agents, such as moisturizing creams, blush, foundation, oral contraceptives, and fluorinated toothpaste (6) (SOR: C).
Several antibiotic regimens are successful in the treatment of perioral dermatitis.
Tetracycline 250 mg twice daily, minocycline 100 mg daily, or doxycycline 100 mg daily for 2 to 3 weeks is the initial treatment. The treatment course may last up to 6 weeks (8) (SOR: B).
For children, pregnant women, or patients with allergies to certain antibiotics, erythromycin 250 mg twice daily for up to 6 weeks is also an option (7) (SOR: C).
Topical treatments can also be used, but often take longer and have been shown to be less effective than oral therapies. Metronidazole 0.75% gel applied twice daily for 14 weeks or 1% cream applied twice daily for 8 weeks has been shown to be useful (9,10) (SOR: C).
Erythromycin 2% gel applied twice daily for several months is also effective (7) (SOR: C).
Discontinuing the steroid was a challenge for our patient
We told our patient to discontinue her steroid cream, and we started her on metronidazole gel.
She returned with significant worsening of her rash, including swelling and erythema.
We therefore prescribed a brief course of prednisone for short-term relief while she was started on oral doxycycline.
After 6 weeks of oral doxycycline therapy, her rash resolved.
At a 6-month follow-up, the patient had experienced no further recurrence of the rash.
CORRESPONDENCE Marc Babaoff, MD, MAHEC Family Medicine Residency Program, 118 W. T. Weaver Boulevard, Asheville, NC 28804;
1. Fitzpatrick TB, Johnson RA, Wolff K. Color Atlas and Synopsis of Clinical Dermatology: Common and Serious Diseases. New York: McGraw Hill; 1997:16–17.
2. White G. Color Atlas of Dermatology. 3rd ed. London: Elsevier Science Ltd.; 2004:89.
3. Hafeez ZH. Perioral dermatitis: an update. Int J Dermatol. 2003;42:514-517.
4. Wilkinson DS, Kirton V, Wilkinson JD. Perioral dermatitis: a 12-year review. Br J Dermatol. 1979;101:245-257.
5. Kalkoff KW, Buck A. Etiology of perioral dermatitis [in German]. Hautarzt. 1977;28:74-77.
6. Hengge UR, Ruzicka T, Schwartz RA, et al. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. 2006;54:1-15.
7. Weber K, Thurmayr R. Critical appraisal of reports on the treatment of perioral dermatitis. Dermatology. 2005;210:300-307.
8. Macdonald A, Feiwel M. Perioral dermatitis: aetiology and treatment with tetracycline. Br J Dermatol. 1972;87:315-319.
9. Miller SR, Shalita AR. Topical metronidazole gel (0.75%) for the treatment of perioral dermatitis in children. J Am Acad Dermatol. 1994;31:847-848.
10. Veien NK, Munkvad JM, Nielsen AO, et al. Topical metronidazole in the treatment of perioral dermatitis. J Am Acad Dermatol. 1991;24:258-260.
Metronidazole 1% gel is available in Ireland as Rozex 0,75% aqu. gel , and Rosex 0,75 cream
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