7/29/2019 Chapter 82.Perioral Dermatitis

1/4

Chapter 82Perioral Dermatitis

Leslie P. Lawley & Sareeta R.S. Parker

PERIORAL DERMATITIS AT A GLANCE

Inflammatory skin disorder of young women and children. Small papules, vesicles, and pustules in perioral, periorbital, and/or perinasal

distribution.

Treatment: stop topical corticosteroid use; initiate 2- to 3-month course of systemicantibiotics (tetracycline family or erythromycin) and/or topical metronidazole

Perioral dermatitis is characterized by small, discrete papules and pustules in a periorificial

distribution, predominantly around the mouth. Because this condition can involve areas other thanthe perioral region, the term periorificial dermatitis has been proposed for this disorder.1,2 The

classic presentation is an eruption with overlapping features of an eczematous dermatitis and an

acneiform eruption. Although initially described in young women of 1525 years of age, perioral

dermatitis is now recognized to occur in children as well.3 A subset of perioral dermatitis shows

granulomas when lesional skin is examined histologically. Several names have been used to describe

this granulomatous form of perioral dermatitis, including granulomatous perioral dermatitis, facial

Afro-Caribbean childhood eruption, and granulomatous periorificial dermatitis.

HISTORICAL ASPECTS

The first reports describing perioral dermatitis appeared in the 1950s; various names were given to

the condition, however, there was a lack of defining clinical criteria. In 1957, Frumess and Lewis

described a light sensitive seborrheid that is generally accepted as the first account of what was

later termed perioral dermatitis by Mihan and Ayres in 1964.6,7 Later descriptions by Cochran and

Thomson8 and Wilkinson, Kirton, and Wilkinson9 further defined this disorder, and more recently

the term periorificial dermatitis has been proposed.2 The condition was first described in children in

the late 1960s.

EPIDEMIOLOGY

Adult perioral dermatitis predominantly affects women. Pediatric perioral dermatitis may have a

slight female preponderance and is seen equally among those of different races.1,10 The

granulomatous form of perioral dermatitis has been reported mostly in children of prepubertal age.5

Perioral dermatitis can occur as early as 6 months.1 An increased prevalence in African-American

children has been reported, but more recent reviews do not support this finding.2,11

ETIOLOGY AND PATHOGENESIS

A relationship of perioral dermatitis to the misuse of topical corticosteroids (fluorinated or

nonfluorinated) has been well established.12 Patients often reveal a history of an acute steroid-

responsive eruption around the mouth, nose, and/or eyes that worsens when the topicalcorticosteroid is discontinued. Dependency on the use of the topical corticosteroid may develop as

7/29/2019 Chapter 82.Perioral Dermatitis

2/4

the patient repeatedly treats the recurrent eruption. In other cases, the condition may worsen with

the application of topical corticosteroids, especially in the granulomatous variant of perioral

dermatitis, which usually occurs in prepubertal children.2 Perioral dermatitis has been reported in

patients using inhaled corticosteroids13 and with inadvertent facial exposure to topical

corticosteroids.14 However, perioral dermatitis is not always linked to topical corticosteroids.9 The

exact cause of perioral dermatitis in these other cases is unclear. Although isolated reports of

affected siblings exist,2,15 no clear genetic predisposition has been noted, nor have specific

environmental exposures been consistently implicated. Of note, the disease is predominant in young

women yet no link to hormonal causes has been found. The initial reports of photosensitivity by

Frumess and Lewis6 were not further substantiated, nor were theories of microbiologic causes such

as infection with Candida, fusiform bacteria, or Demodex folliculorum.16 Cases of allergic contact

with fluorides or other components in toothpaste and dentifrices have also been reported, however,

use of these agents after clearing of the perioral dermatitis without further eruption has also been

described. Patch testing in a small series of patients led to few positive results, and these were not

considered relevant.9

In the past, authors have considered the relationship of perioral dermatitis to acne rosacea,

however, the clinical features are distinct (see Section Differential Diagnosis). In perioral

dermatitis, the histopathologic findings are variable and are dependent on the form of perioral

dermatitis. In a histopathologic review of 26 patients with the nongranulomatous form, follicular

spongiosis and eczematous changes were prominent features, suggesting that perioral dermatitis is

distinct from rosacea.17 A lymphohistiocytic infiltrate and occasional plasma cells were noted in a

perifollicular and perivascular distribution in this series. In granulomatous perioral dermatitis,

histopathology demonstrates follicular hyperkeratosis, edema and vasodilatation in the papillary

dermis, perivascular and parafollicular infiltrates of lymphocytes, histiocytes, andpolymorphonuclear leukocytes with occasional epithelioid granulomas and giant cells, similar to the

histopathologic changes in acne rosacea.5,18

CLINICAL FINDINGS

The primary lesions of perioral dermatitis are discrete and grouped erythematous papules, vesicles,

and pustules (Figs. 82-1 and 82-2). The lesions are often symmetric but may be unilateral and appear

in the perioral, perinasal, and/or periocular regions (Figs. 82-2 and 82-3 and eFigs. 82-3.1 and 82-3.2

in online edition). In a retrospective review of 79 children with perioral dermatitis, isolated perioral

involvement was present in only 39%, and in rare cases nonperioral regions were involved

exclusively.1 Background erythema and/or scale may be present. A distinct 5-mm clear zone at the

vermilion edge is well described (Fig. 82-2). The granulomatous variant of perioral dermatitis

presents with small flesh-colored, erythematous, or yellowbrown papules, some with confluence,

and shares the distribution of perioral dermatitis in adults (Fig. 82-3). In addition, lesions have been

reported to appear on the ears, neck, scalp, trunk, labia majora, and extremities

Occasionally, an associated burning sensation or itching is reported, and intolerance to moisturizers

and other topical products is described.1,9 In a few cases of granulomatous perioral dermatitis, an

associated blepharitis or conjunctivitis has been reported.11 Systemic findings and regional

lymphadenopathy are absent.

DIFFERENTIAL DIAGNOSIS

7/29/2019 Chapter 82.Perioral Dermatitis

3/4

The differential diagnosis of nongranulomatous and granulomatous perioral dermatitis is outlined in

Box 82-1.1924 Both forms of perioral dermatitis lack systemic symptoms and a thorough history

and physical examination are generally sufficient to establish the diagnosis. However, in some cases

histopathological evaluation of lesional skin, chest radiography, and/or ophthalmologic examination

may be necessary, particularly with the granulomatous variant.11 Sarcoidosis in young children is

rare and often accompanied by systemic signs and symptoms such as weight loss, fatigue, joint

pains, lymphadenopathy, and uveitis.5,25 At least some of the reported cases of sarcoidosis in young

children represent Blau syndrome with underlying mutations in CARD15/NOD2 (see Chapter 134).

COMPLICATIONS

The majority of cases of perioral dermatitis and granulomatous perioral dermatitis resolve without

sequelae or relapse. However, there are rare reports of scarring

PROGNOSIS AND CLINICAL COURSE

Perioral dermatitis is usually a self-limited disorder that evolves over a few weeks and resolves over

months or rarely years. The condition may take on a waxing and waning course, often with a

tendency to progress (granulomatous form). If treated with topical corticosteroids alone, recurrent

episodes on withdrawal of therapy or with continuing therapy are typical. With appropriate

intervention the condition resolves with rare recurrences.

TREATMENT

If topical corticosteroids are being used, they should be discontinued. If fluorinated corticosteroids

are being applied, initial substitution with a low-potency hydrocortisone cream may minimize a flare

of the dermatitis. Patients should be educated about the link between application of topical

corticosteroids and exacerbation of the dermatitis.

In most cases, effective therapy is oral tetracycline, doxycycline, or minocycline, for a course of 8 to

10 weeks, with a taper over the last 2 to 4 weeks. In children under 8 years of age, nursing mothers,

or tetracycline-allergic patients, oral erythromycin is recommended. Not uncommonly, patients

require continued low-dose systemic antibiotic therapy for months or sometimes years to maintain

control. In recalcitrant cases, isotretinoin may be considered.27

Topical antibiotic therapy, most commonly with topical metronidazole, should be initiated

concurrently with the systemic antibiotic. For milder cases, topical metronidazole alone maysuffice.1,28,29 In a retrospective review of 79 children, best outcomes were associated with the use

of topical metronidazole, oral erythromycin, or both.1 Response is generally noted within 23

months. Other options include topical clindamycin or erythromycin, topical sulfur-based

preparations, and topical azelaic acid.30 Reports of successful use of topical calcineurin inhibitors

exist, particularly in adults; however, caution is advised given the occasional reports of

granulomatous eruptions after the use of these agents.3135 Ointment preparations should

generally be avoided in the treatment of perioral dermatitis. Photodynamic therapy with topical 5-

aminolevulinic acid has shown promise for treating perioral dermatitis in one report.36

PREVENTION

7/29/2019 Chapter 82.Perioral Dermatitis

4/4

The only widely accepted factor that may predispose to the development of perioral dermatitis is

the use of topical corticosteroids. Avoiding facial skin exposure to these products may prevent the

eruption in some case