Perioral dermatitis: It's not every rash that appears around the mouth

A novice dermatologist may sometimes have a rough time in diagnosing perioral dermatitis and distinguishing it from its common imitators.

Recognizing the etiologic factors that may cause or exacerbate perioral dermatitis and choosing the appropriate treatment regimens for this relatively common skin rash can, at times, prove difficult, according to Nikki A. Levin M.D. Ph.D., associate professor of medicine in the Division of Dermatology at UMass Medical School, Worcester, Mass.

She says that the two groups mostly affected by this rash are children between 7 months and 13 years of age and women between 16 and 45 years of age.

Most clinicians believe that potent topical corticosteroid therapy is either the root or an exacerbating factor causing this rash to appear, with 85 percent to 90 percent of the presenting cases reporting a history of corticosteroid usage. Atopic individuals and patients who use or ?overuse? moisturizers and cosmetic ingredients, as well as those patients who use toothpastes containing fluoride and anti-tartar agents are all subject to suffer from this sometimes unsightly rash. Hormonal factors are also strongly implicated due to the staggering female predominance of cases.

Patients usually present with a small, scaly, erythematous, papular or papulopustular rash that is asymptomatic, mildly sore, or even pruritic, and is commonly concentrated around the mouth with a narrow zone of sparing around the vermilion border of the lips, the chin, upper lip, and perinasal skin. The periocular skin, eyelids, glabella and forehead are less common sites but may also be the target of this rash, even in the absence of perioral involvement.

The list of differential diagnoses of perioral dermatitis is long and includes rosacea, seborrheic dermatitis, lip licker?s dermatitis, acne vulgaris, contact dermatitis, Demodex infestation, papular sarcoidosis, lupus miliaris disseminatus faciei, familial juvenile systemic granulomatosis, eruptive syringomas or xanthomas, and acrodermatitis enterpathica. According to Dr. Levin, if the clinician pays close attention to morphology and location of the rash, most of the differential diagnoses can be discarded, and an accurate diagnosis can be made.

Dr. Levin stresses that potent topical corticosteroid therapy as well as any facial moisturizers and make-ups must be immediately discontinued and is the first step to a successful therapy. Oral tetracycline antibiotics are the gold standard of therapy here. Alternative oral medications include erythromycin, dapsone, clotrimazole, and isotretinoin. Topical therapy consists of metronidazole cream, erythromycin solution or ointment, clindamycin gel, 20 percent azelaic acid, adapalene gel, benzoyl peroxide, tacrolimus 0.03 percent ointment, and even 0.5 percent sulfur cream. DT

Dr. Levin is giving a full presentation at FOC814 from 12:45 to 1:45 p.m. today.