Perioral dermatitis, also known as periorificial dermatitis, is a common type of inflammatory 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. 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.
The cause is unclear. Topical steroids are associated with the condition and moisturizers and cosmetics may contribute. 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. It is considered a disease of the hair follicle with biopsy samples showing microscopic changes around the hair follicle. Diagnosis is based on symptoms.
Treatment is typically by stopping topical steroids, changing cosmetics, and in more severe cases, taking tetracyclines by mouth. Stopping steroids may initially worsen the rash. The condition is estimated to affect 0.5-1% of people each 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.
History The disorder appears to have made a sudden appearance in 1957 with a case of 'light sensitive seborrhoeid', which is said to be the first nearest description of the condition. By 1964, the condition in adults was widely known as perioral dermatitis, but without clear clinical criteria. In 1970, the condition was recognized in children. Whether all rashes around the mouth are perioral dermatitis has been frequently debated. That this condition should be renamed periorificial dermatitis has been proposed. 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.
Signs and symptoms
A stinging and burning sensation with rash is often felt and noticed, but itching is less common. Often, the rash is steroid responsive, initially improving with application of a topical steroid. The redness caused by perioral dermatitis has been associated with variable levels of depression and anxiety.
Initially, there may be small pinpoint papules on 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. These areas of skin are felt to be drier and therefore there is a tendency to moisturize them more frequently. Hence, they do not tolerate drying agents well, and they often worsen the rash.
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 is also often present, especially in older people. Acne can be distinguished by the presence of comedones and by its wider distribution on the face and chest. There are no comedones in perioral dermatitis.
A variant of perioral dermatitis called granulomatous perioral dermatitis (GPD) is often seen in prepubertal children or in darker-skin phenotypes. GPD lesions may appear yellow on a diascopy. Patients report irritation but are usually asymptomatic. For children with GPD, a skin biopsy showing a granulomatous infiltrate is needed to confirm diagnosis in an atypical patient. If the GPD is mild, treatment is not mandatory.
Causes The exact cause of perioral dermatitis is unclear; however, some associations are suspected. There have been clinical trials examining the link between perioral dermatitis and steroids, infections, and typical facial products. These factors may play a role in the development of perioral dermatitis. 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. An underlying cause can not always be known for patients as the exact mechanism of action to develop perioral dermatitis is not known.
Corticosteroids Perioral dermatitis can occur with corticosteroids. Corticosteroids are anti-inflammatory medications used to reduce swelling and redness caused by the body. There are different forms of steroids, many of which can contribute to the development of perioral dermatitis. Some of these are topical corticosteroids, oral corticosteroids, and inhaled corticosteroids. Clinical trials have shown 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 the development of perioral dermatitis with stronger steroids. It has also been seen that chronic use of steroids shows 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. Perioral dermatitis tends 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.Reports of perioral dermatitis in renal transplant recipients treated with oral corticosteroids and azathioprine have been documented.
Infections Topical corticosteroids may lead to an increase in microorganism density in the hair follicle. Microorganisms are small living things that a person is not able to see without a microscope. Normally, people have microorganisms all over their bodies, but corticosteroids can change the type and amount. 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. There are different types of the infections such as bacterial, yeast, and parasitic. From different clinical trials, it seems that a bacterial infection is more likely to lead to perioral dermatitis than the other types.
Cosmetics Cosmetics play an important role as potential causal factors for perioral dermatitis. Cosmetics in this case include a variety of products that are applied to the face such as moisturizer, foundation, and sunscreen. It is especially seen when these products contain petroleum, paraffin, or isopropyl myristate. Applying large quantities of a moisturizing creams regularly causes persistent hydration of the layer which may cause impairment and occlusion of the barrier function, irritation of the hair follicle, and proliferation of skin flora. Occlusion is the sealing of the moisture. Proliferation is when cells continue to divide to create new healthy cells. This is a process that cells of all kinds normally and often do. For some people, this act of moisturizing excessively can affect the typical proliferation of skin flora. Skin flora are the typical bacteria and cells that sit on a person's face. Transepidermal water loss is also seen as associated with perioral dermatitis. Transepidermal water loss is water that is lost from the inside of the body by going through the skin to the outside world. There are associations that water loss is greater in older adults, but perioral dermatitis can still occur in younger people. Barrier dysfunction is seen as a large cosmetic association with perioral dermatitis. Combining this with night cream and foundation significantly increases the risk of perioral dermatitis 13-fold. In a similar fashion, foundation and sunscreen also create extra occlusive layers that may affect the skin. Physical sunscreens also have been seen to have an associations These are potential associations to perioral dermatitis and thoughts of how it may cause perioral dermatitis; however, the exact pathology is still unknown. This also does not mean that those who use these products will be sure to develop perioral dermatitis.
Other Potential Causes Various other potential factors are suspected to cause or worsen perioral dermatitis; however, sufficient research has not been conducted to demonstrate a link as strong as that with corticosteroids. Hormonal changes may be linked to causing perioral dermatitis. Oral contraceptives (birth control pills) may also have a link, as they significantly impact the hormonal balance of the people taking them. Hormones are natural chemicals in the body that act as messengers by relaying information to different parts of the body. The body normally regulates these levels; however, they can be changed by other factors such as oral contraceptives. Gastrointestinal (GI) changes may also be linked with perioral dermatitis. The GI system includes all the organs for food to be broken down, absorbed, and excreted out of the body. The condition may be potentially worsened by fluoridated toothpaste, excessive wind, or heat. The possibility of an association with wearing a veil has been documented as well. Some other miscellaneous factors include emotional stress, malabsorption, and latex gloves.
Perioral dermatitis can also be caused by other factors, such as stress, oily secretions, and fluid intake, all of which were impacted as COVID cases increased, which further increased the rates of wearing masks. This, in turn, resulted in increased levels of stress and oil secretions along the face and decreased water intake.
Pathophysiology The pathophysiology of perioral dermatitis is related to disease of the hair follicle, as is now included in the ICD-11, due to be finalized in 2018. Lip licker's dermatitis or perioral irritant contact dermatitis due to lip-licking is considered a separate disease categorized under irritant contact dermatitis due to saliva.
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.
There is a possible discovery of new information that perioral dermatitis develops due to damage to the skin barrier in the facial area, which may lead to the patient's skin becoming exposed to both internal and external factors that contribute to the development of perioral dermatitis.
Diagnosis A diagnosis of perioral dermatitis is typically made based on the rash's characteristics. A skin biopsy is usually not required to make the diagnosis, but it can be helpful to rule out other skin diseases that may resemble perioral dermatitis. Extended patch testing may also be useful to rule out allergic contact causes. If the skin biopsy shows signs of other components such as bacteria, the healthcare workers can do further lab testing, such as culture or other tests like a diascopy.
Other skin diseases that may resemble perioral dermatitis include: Rosacea Acne vulgaris Seborrheic dermatitis Allergic contact dermatitis Irritant contact dermatitis Angular cheilitis Sarcoidosis Lip licker's cheilitis Demodex folliculitis Tinea faciei Syringomas
Treatment Multiple treatment regimes are available, and treatment algorithms have been proposed.
Treatment regimens are advised to treat perioral dermatitis using the lowest possible dose for antibiotics and other therapies.