Wikipedia

Perioral dermatitis

(Redirected from Periorificial dermatitis)
Not to be confused with Lip licker's dermatitis.

Perioral dermatitis, also known as periorificial dermatitis, is a common type of skin rash. Symptoms include multiple small (1–2 mm) bumps and blisters sometimes with background redness and scale, localized to the skin around the mouth and nostrils. Less commonly the eyes and genitalia may be involved.[2] It can be persistent or recurring and resembles particularly rosacea and to some extent acne and allergic dermatitis. The term "dermatitis" is a misnomer because this is not an eczematous process.[3]

Perioral dermatitis
Other namesPeriorificial dermatitis
Papules around mouth and nostrils with some background redness and sparing of vermillion border
SpecialtyDermatology
SymptomsPapules, pustules, red skin
ComplicationsSkin infection
CausesUnknown[1]
Risk factorsTopical steroids, cosmetics, moisturiser
Diagnostic methodBased on symptom and appearance
Differential diagnosisRosacea, acne
TreatmentNone, tetracycline

The cause is unclear.[1] Topical steroids are associated with the condition and moisturizers and cosmetics may contribute.[3] The underlying mechanism may involve blockage of the skin surface followed by subsequent excessive growth of skin flora. Fluoridated toothpaste and some micro-organisms including Candida may also worsen the condition, but their roles in this condition are unclear.[4] It is considered a disease of the hair follicle with biopsy samples showing microscopic changes around the hair follicle. Diagnosis is based on symptoms.[4]

Treatment is typically by stopping topical steroids, changing cosmetics, and in more severe cases, taking tetracyclines by mouth.[1][5] Stopping steroids may initially worsen the rash. The condition is estimated to affect 0.5-1% of people a year in the developed world. Up to 90% of Those affected are women between the ages of 16 and 45 years, though it also affects children and the elderly, and has an increasing incidence in men.[6][7]

History

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The disorder appears to have made a sudden appearance with a case of 'light sensitive seborrhoeid' in 1957, which is said to be the first nearest description of the condition. By 1964, the condition in adults became popularly known as perioral dermatitis, but without clear clinical criteria.[2] In 1970, the condition was recognised in children. That all rashes around the mouth are perioral dermatitis has since been frequently debated.[8] That this condition should be renamed periorificial dermatitis has been proposed.[2] Darrell Wilkinson was a British dermatologist who gave one of the earliest 'definitive' descriptions of 'perioral dermatitis' and noted that the condition was not always associated with the use of fluoridated steroid creams.[7][9][10]

Signs and symptoms

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A stinging and burning sensation with rash is often felt and noticed, but itching is less common.[6] Often the rash is steroid responsive, initially improving with application of topical steroid.[1] The redness caused by perioral dermatitis has been associated with variable level of depression and anxiety.[9]

Initially, there may be small pinpoint papules either side of the nostrils. Multiple small (1-2mm) papules and pustules then occur around the mouth, nose and sometimes cheeks. The area of skin directly adjacent to the lips, also called the vermillion border, is spared and looks normal. There may be some mild background redness and occasional scale.[11] These areas of skin are felt to be drier and therefore there is a tendency to moisturise them more frequently. Hence, they do not tolerate drying agents well and the rash can be worsened by them.[7]

Perioral dermatitis is also known by other names including rosacea-like dermatoses, periorofacial dermatitis and periorificial dermatitis. Unlike rosacea which involves mainly the nose and cheeks, there is no telangiectasia in perioral dermatitis. Rosacea also has a tendency to be present in older people. Acne can be distinguished by the presence of comedones and by its wider distribution on the face and chest.[9] There are no comedones in perioral dermatitis.[3]

Causes

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The exact cause of perioral dermatitis is unclear; however there are some associations that are suspected. There have been clinical trials to look at the link between perioral dermatitis and steroids, infections, and typical face products.[12] These factors may play a role in the development of perioral dermatitis.[1][2] Although light exposure has been discounted as a causal factor, some reports of perioral dermatitis have been made by some patients receiving Psoralen and ultraviolet A therapy.[11]

Corticosteroids

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Perioral dermatitis can occur with corticosteroids, which is often shortened to steroids. Steroids are anti-inflammatory drugs so they are used to reduce swelling and redness that is caused by the body. There are different forms of steroids, many of which can contribute to the development of perioral dermatitis.[12] Some of these are topical corticosteroids, oral corticosteroids, and inhaled corticosteroids. There have been clinical trials that show a correlation between these corticosteroids; however, a direct cause has not been confirmed. The highest link seems to be with topical corticosteroids in comparison to the others and there seems to be a higher chance of development of perioral dermatitis with greater strength steroids.[12][11] It has also been seen that chronic use of steroids show a higher rate of developing perioral dermatitis. Discontinuing the steroids often initially worsens the dermatitis, which leads to some conflicting beliefs as some people believe the steroids were initially controlling the condition.[3] Perioral dermatitis has a tendency to occur on the drier parts of the face and can be aggravated by drying agents including topical benzoyl peroxide, tretinoin and lotions with an alcohol base.[7]Reports of perioral dermatitis in renal transplant recipients treated with oral corticosteroids and azathioprine have been documented.[4]

Infections

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Topical corticosteroids may lead to increase micro-organism density in the hair follicle.[11] Micro-organisms are small living things that a person is not able to see without a microscope. Normally people have micro-organisms all over there body but the type and amount can be quickly changed by corticosteroids. This may lead to an infection. The role of infectious agents such as Candida species, Demodex folliculorum, and fusobacteria has not been confirmed, but could be potential causes for development as well.[13][12] There are different types of the infections such as bacterial, yeast, and parasitic. From different clinical trials, it seems that a bacteria infection is more like to lead to perioral dermatitis than the other types.[12]

Cosmetics

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Cosmetics play an important role as causal factors for perioral dermatitis.[4] Regular generous applications of moisturising creams cause persistent hydration of the layer causing impairment and occlusion of the barrier function, irritation of the hair follicle, and proliferation of skin flora. Combining this with night cream and foundation significantly increases risk of perioral dermatitis 13-fold.[7][9]

Other potential causes

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The condition may be potentially worsened by fluoridated toothpaste and inhaled corticosteroids.[1][2] A high prevalence of atopy has been found in those with perioral dermatitis.[11][13] The possibility of an association with the wearing of the veil in Arab women has been documented.[4]

Some other miscellaneous factors include stress, malabsorption, and latex gloves.[14]

Pathophysiology

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The pathophysiology of perioral dermatitis is related to disease of the hair follicle as is now included in the ICD-11 due to be finalised in 2018.[15] Lip licker's dermatitis or perioral irritant contact dermatitis due to lip-licking is considered a separate disease categorised under irritant contact dermatitis due to saliva.[16]

Perioral dermatitis is frequently histologically similar to rosacea with the two conditions overlapping considerably. There is a lymphohistiocytic infiltrate with perifollicular localization and marked granulomatous inflammation. Occasionally, perifollicular abscesses may be present when pustules and papules are the dominant clinical findings.[6]

Diagnosis

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A diagnosis of perioral dermatitis is typically made based on the characteristics of the rash. A skin biopsy is usually not required to make the diagnosis but can be helpful to rule out other skin diseases which may resemble perioral dermatitis. Extended patch testing may be useful to also rule out allergic contact causes.[4]

Other skin diseases that may resemble perioral dermatitis include:

Treatment

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Multiple treatment regimes are available and treatment algorithms have been proposed.[1]

Treatment regimens are advised to treat perioral dermatitis using the lowest possible dose for antibiotics and other therapies. [17]

Perioral dermatitis will usually resolve within a few months without medication, by limiting the use of irritants, including products with fragrance, cosmetics, benzoyl peroxide, occlusive sunscreens, and various acne products. This is called zero treatment. Topical corticosteroids should be stopped entirely if possible.[5][18] Abrupt discontinuation of a topical corticosteroid may lead to rebound flares.[19] If the flare proves intolerable, temporary use of a less potent topical corticosteroid can often be helpful.[13] Slowly reducing the use of topical corticosteroids over time can help prevent rebound flares. [19]

Medication

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A number of medications, either applied directly to the skin or taken by mouth, may hasten recovery. These include tetracycline, doxycycline, and erythromycin.[20] Tetracycline is given at a daily dosage of 250 to 500 mg twice a day for 4 to 8 weeks.[19] Gastrointestinal issues, diarrhea, and photosensitivity are possible short term side effects when taking tetracycline.[19] Sarecycline, a narrow-spectrum tetracycline antibiotic, has a lower potential of causing bacterial resistance and gastrointestinal issues compared to other tetracycline medications. Possible side effects of sarecycline include mainly nausea and sunburn being very rare.[21] Pregnant women and pediatric patients can not take tetracycline. [19] Erythromycin is often given as an alternative to those that can't take tetracycline, given at a daily dosage of 250 to 500 mg. Erythromycin may be used as a cream.[5] Doxycycline is a second generation tetracycline with improved absorption and a broader anti-bacterial spectrum. [19] Doxycycline is most often the first antibiotic drug choice, given at a daily dosage of 100 mg for up to a month before considering tapering off or stopping. Sometimes, longer duration of low doses of doxycycline are required.[7] Possible side effects of doxycycline include gastrointestinal issues and irritation in the esophagus. [19]

Metronidazole is less effective, but is available in a gel and can be applied twice daily. For pediatric patients, metronidazole can be used as an alternative to tetracycline. Metronidazole comes in various concentrations ranging from 0.75% to 2%. Higher concentrated metronidazole did not equate to shorter time to cure times. [19] If the perioral dermatitis was triggered by a topical steroid then pimecrolimus cream has been suggested as effective in improving symptoms.[7] However, this has also been documented to cause the condition.[3] Topical pimecrolimus is often used in treating corticosteroid induced perioral dermatitis due to it being a non-steroid based cream. Pimecrolimus is generally well tolerated with a rare side effect of a burning sensation at the application site. [19]

Topical adapalene has been reported to resolve a case of perioral dermatitis in 4 weeks without any side effects. The dose used was 1% adapalene gel once a day at night. The patient did not have recurrence during the 8-month follow up period. [19][22]

The most common medications to help treat perioral dermatitis are oral tetracycline, pimecrolimus cream, and azelaic gel. However, some of these medications can't be used for prolonged periods of time, otherwise they will no longer be effective against the disease. For example, use of pimecrolimus cream for more than four weeks will be ineffective, while use of azelaic gel for more than six weeks will be ineffective. While these two medications previously mentioned decrease in effectiveness after a certain period of time, oral tetracycline, on the other hand, have been shown to have decreased effectiveness if used prior to twenty days of disease diagnosis.[23]

While there may be other topical medications that can be effective against perioral dermatitis, such as erythromycin emulsion or metronidazole cream, studies have shown that their effectiveness varied amongst different random controlled trials. As a result, these two topical medications, amongst others, may not be the ideal solution for perioral dermatitis.[24]

For more rare cases, cefcapene pivoxil hydrochloride, a beta lactam antibiotic, has been used in treating perioral dermatitis presumably caused by Fusobacteria. Improvement was visible in 1 to 2 weeks and cured in 2 to 5 weeks.[19] Isotretinoin was used in treating granulomatous perioral dermatitis at a dose of 0.7 mg/kg/day isotretinoin for 20 weeks. However, the patient was also taking a series of combination therapies. Isotretinoin also requires long term monitoring for potential side effects. [19]

Prognosis

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Perioral dermatitis is likely to fully resolve with short courses of antibiotics but if left untreated it can persist for years and take a chronic form.[11]

In some cases, it can be resolve for the patient to stop taking external factors that may play a role in the development of perioral dermatitis.[25]

Improvement with tetracyclines is usually seen after 4 days and significantly so after 2 weeks.[3]

Epidemiology

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Most commonly in women between the ages of 16 and 45 years, perioral dermatitis also occurs equally in all racial and ethnic backgrounds and include children as young as three months and is increasingly reported in men. In children, females are more likely affected. It has an incidence of up to 1% in developed countries.[6]

Impacts

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Many individuals who have perioral dermatitis, amongst other skin issues, have an increase risk of experiencing mental health issues, such as, depression, anxiety, and stress.[26]

See also

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Wikimedia Commons has media related to Perioral dermatitis.

References

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  1. ^ a b c d e f g Tempark T, Shwayder TA (April 2014). "Perioral dermatitis: a review of the condition with special attention to treatment options". American Journal of Clinical Dermatology. 15 (2): 101–113. doi:10.1007/s40257-014-0067-7. PMID 24623018. S2CID 9113871.(subscription required)
  2. ^ a b c d e Goldsmith LP, Katz SI, Gilchrest BA, Paller AS (2012). "Chapter 82: Perioral dermatitis". Fitzpatrick's Dermatology in General Medicine (8th ed.). The McGraw-Hill Companies. pp. 926–928. ISBN 978-0-07-166904-7.
  3. ^ a b c d e f Du Vivier A (2013). Atlas of clinical dermatology (4th ed.). Elsevier Saunders. pp. 609–610. ISBN 978-0-7020-3421-3.
  4. ^ a b c d e f Patterson JW (2019). "8. The granulomatous reaction pattern". Weedon's Skin Pathology (5th ed.). Elsevier Health Sciences. p. 219. ISBN 978-0-7020-7582-7.
  5. ^ a b c Hall CS, Reichenberg J (August 2010). "Evidence based review of perioral dermatitis therapy". Giornale Italiano di Dermatologia e Venereologia. 145 (4): 433–444. PMID 20823788.(subscription required)
  6. ^ a b c d e Kammler HJ, Zaenglein AL (November 2020). Talavera F, James WD (eds.). "Perioral Dermatitis: Background, Pathophysiology, Epidemiology". Medscape. WebMD LLC.
  7. ^ a b c d e f g Habif TP (2009). "7. Acne, Rosacea, and Related Disorders". Clinical Dermatology (5th ed.). Mosby, Elsevier. pp. 253–255. ISBN 978-0-7234-3541-9.
  8. ^ Lee GL, Zirwas MJ (July 2015). "Granulomatous Rosacea and Periorificial Dermatitis: Controversies and Review of Management and Treatment". Dermatologic Clinics. 33 (3): 447–455. doi:10.1016/j.det.2015.03.009. PMID 26143424.
  9. ^ a b c d Marks R (2007). "Chapter 3: Perioral dermatitis and miscellaneous inflammatory disorders of unknown origin". Facial Skin Disorders. CRC Press. pp. 32–39. ISBN 978-1-4356-2622-5.
  10. ^ "Peter Edward Darrell Sheldon Wilkinson". Munk's Roll. London: Heritage Centre, Royal College of Physicians. Archived from the original on 10 November 2017. Retrieved 6 November 2017.
  11. ^ a b c d e f Layton AM, Eady EE, Zouboulis CC (2016). "Chapter 90: Acne". In Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer D (eds.). Rook's Textbook of Dermatology (Ninth ed.). Chichester, West Sussex: John Wiley & Sons. ISBN 978-1-118-44119-0. OCLC 930026561.
    Powell FC (2016). "Chapter 91: Rosacea". In Griffiths C, Barker J, Bleiker T, Chalmers R, Creamer D (eds.). Rook's Textbook of Dermatology (Ninth ed.). Chichester, West Sussex: John Wiley & Sons. ISBN 978-1-118-44119-0. OCLC 930026561.
  12. ^ a b c d e Searle T, Ali FR, Al-Niaimi F (December 2021). "Perioral dermatitis: Diagnosis, proposed etiologies, and management". Journal of Cosmetic Dermatology. 20 (12): 3839–3848. doi:10.1111/jocd.14060. PMID 33751778.
  13. ^ a b c Lebwohl MG, Heymann WR, Berth-Jones J, Coulson IH (2018). Treatment of Skin Disease: Comprehensive Therapeutic Strategies (5th ed.). Elsevier. pp. 619–620. ISBN 978-0-7020-6912-3.
  14. ^ Alawi F, Shields BE, Omolehinwa T, Rosenbach M (2020-10-01). "Oral Granulomatous Disease". Dermatologic Clinics. Oral Medicine in Dermatology. 38 (4): 429–439. doi:10.1016/j.det.2020.05.004. ISSN 0733-8635.
  15. ^ "ICD-11 Beta Draft - Mortality and Morbidity Statistics". icd.who.int. Retrieved 2017-11-09.
  16. ^ "ICD-11 Beta Draft - Mortality and Morbidity Statistics". icd.who.int. Retrieved 2017-11-14.
  17. ^ Ellis CN, Stawiski MA (1982). "The Treatment of Perioral Dermatitis, Acne Rosacea, and Seborrheic Dermatitis". Medical Clinics of North America. 66 (4): 819–830. doi:10.1016/S0025-7125(16)31396-7.
  18. ^ Oakley A (2016). "Periorificial dermatitis". DermNet. New Zealand. Retrieved 26 August 2020.
  19. ^ a b c d e f g h i j k l Tempark T, Shwayder TA (2014-04-01). "Perioral Dermatitis: A Review of the Condition with Special Attention to Treatment Options". American Journal of Clinical Dermatology. 15 (2): 101–113. doi:10.1007/s40257-014-0067-7. ISSN 1179-1888.
  20. ^ "Perioral dermatitis". Medline Plus. U.S. National Library of Medicine. 11 December 2009. Retrieved 7 August 2010.
  21. ^ Swenson K, Stern A, Graber E (June 2024). "A Retrospective Review of a Cohort of Patients with Periorificial Dermatitis Treated with Sarecycline". The Journal of Clinical and Aesthetic Dermatology. 17 (6): 50–54. PMC 11189645. PMID 38912196.
  22. ^ Jansen T (2002). "Perioral dermatitis successfully treated with topical adapalene". Journal of the European Academy of Dermatology and Venereology. 16 (2): 175–177. doi:10.1046/j.1468-3083.2002.00392_4.x. ISSN 0926-9959.
  23. ^ Gray NA, Tod B, Rohwer A, Fincham L, Visser WI, McCaul M (March 2022). "Pharmacological interventions for periorificial (perioral) dermatitis in children and adults: a systematic review". Journal of the European Academy of Dermatology and Venereology. 36 (3): 380–390. doi:10.1111/jdv.17817. PMID 34779023.
  24. ^ Weber K, Thurmayr R (2005). "Critical appraisal of reports on the treatment of perioral dermatitis". Dermatology. 210 (4): 300–307. doi:10.1159/000084754. PMID 15942216.
  25. ^ Tolaymat L, Hall MR (2024), "Perioral Dermatitis", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 30247843, retrieved 2024-07-25
  26. ^ Salari N, Heidarian P, Hosseinian-Far A, Babajani F, Mohammadi M (2024). "Global Prevalence of Anxiety, Depression, and Stress Among Patients with Skin Diseases: A Systematic Review and Meta-analysis". Journal of Prevention. 45 (4): 611–649. doi:10.1007/s10935-024-00784-0. ISSN 2731-5533.
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