Perioral Dermatitis Treatment Tips
Perioral dermatitis is a rash on the facial skin that usually happens around the mouth and lips, as the name implies. However, it can also occur around the nose or eyelids so the “oral” term is not entirely accurate. When it occurs around the eyes, we call it “periocular perioral dermatitis.” You have to love the terminology work-around!
The important point is that, regardless of which facial “orifice” the dermatitis starts with, the characteristics of, and experience you have with, the rash will be similar.
What does perioral dermatitis look like?
Perioral dermatitis looks like a combination of a dermatitis and acne pustules or even small acne-like blisters.
The dermatitis is usually bright red and the pimples may sting. Some sources say there is no itching, but that is not my experience. I, and my patients, have experienced itching with perioral dermatitis – Yes, I have had it several times.
The skin rash is usually grouped together and gradually increases to involve more skin. It often starts at the angles of the lips, opening of the nose or corners of the eyes. It eventually spreads out from there.
If not diagnosed and treated early, perioral dermatitis can become “granulomatous,” meaning the red bumps get really deep and stubborn. This form is at higher risk for scarring or leaving lasting marks on the skin.
What are common causes of a red rash around the mouth, eyes or nose?
Perioral dermatitis is not the only rash that can surround the skin around your mouth, nose or eyes.
Seborrheic dermatitis can occur in the nasolabial folds that run from the creases of your nose to the sides of your lips. In my experience, many people with perioral dermatitis also have seborrheic dermatitis (as evidenced by scale or redness along the creases of the nose).
You can also have an allergic contact dermatitis around your lips that will look like a rash encircling your mouth. It can happen around your eyelids too.
The skin around the openings of your nose can develop chapping when you frequently blow your nose. It can also be prone to impetigo because the germ, Staph aureus, can reside in your nose.
The best treatment always starts with an accurate diagnosis, so when in doubt, see your doctor.
Who gets perioral dermatitis?
Anyone can develop perioral dermatitis, though it is not that common.
- Under 1% of people in the U.S. develop perioral dermatitis.
- 90% of the people who get perioral dermatitis are women.
- Most people who have perioral dermatitis are 20-45 years old.
7 causes of perioral dermatitis.
The cause of perioral dermatitis is unknown. However, there are some associations:
- Using cortisone cream on the face can lead to perioral dermatitis.
The cortisone creams most likely to cause perioral dermatitis are the halogenated corticosteroids. These are cortisone medicines that have special structures that include halogen atoms like chlorine or fluorine, along with the cortisone part of the molecule that makes up the medicine.
They are prescription cortisones, and it is one of several important reasons why using prescription cortisone on the face needs to be medically-supervised and done with care.
- The use of cortisone inhalers for asthma can lead to perioral dermatitis.
- Fluoride in dental products have also been linked to perioral dermatitis.
We take people off fluoride-fortified dental care products when they have perioral dermatitis.
- Other possible links have been made to an ingredient in skin care products called isopropyl myristate.
- Even the use of petrolatum or paraffin have been potentially associated with causing perioral dermatitis.
- Candida yeast and fusobacteria type of bacteria are seen on skin with perioral dermatitis.
With all these connections, however, we still don’t really know why causes perioral dermatitis.
- Rosacea and perioral dermatitis share some similar features, though the areas of skin involved are different.
Demodex mites play a role in rosacea. For this reason, demodex mites deserve consideration in the presence of perioral dermatitis if the condition persists or recurs.
How do you treat perioral dermatitis?
Every case of perioral dermatitis is different.
- The first treatment step for perioral dermatitis is to remove all irritating skin care products and medicines. These include acne and anti-aging medicines like Retin A, which can inflame the skin and cause more irritation.
We create a very gentle and healing skin-care routine that allows the skin to heal. This involves using gentle cleansers and moisturizers until the skin heals.
It is important to understand that the areas of skin with active perioral dermatitis have a broken skin barrier and are easily irritated – much like putting lemon juice on a cut. It is important not to use harsh soaps, rubbing alcohol or anything on the skin that stings or is potentially irritating.
First and foremost, it is important to create a basic skin care routine that supports healing and does not irritate or provoke further worsening of perioral dermatitis.
To do this:
- Second, dermatologists use topical medicines to treat the involved areas of skin.
This often starts with topical antibiotics such as Metrogel, which is a rosacea medicine.
Other topical antibiotics like erythromycin or clindamycin can be used, too, but only in the forms that do not contain alcohol or irritating bases.
- Third, we may layer an anti-yeast medicine such as topical clotrimazole or ketoconazole creams on top of the antibiotic.
If the inflammation is severe, we additionally layer a non-halogenated/low-potency cortisone cream like hydrocortisone butyrate or over-the-counter hydrocortisone. This needs to be supervised by a doctor because these topical medicines are used for many weeks to months. We aim to stop the cortisone as soon as possible to prevent side effects.
As mentioned before, cortisone has side effects and requires medical supervision. For example, using cortisone cream around the eyes can cause permanent eye damage. It can also cause skin thinning.
- Oral antibiotics may be used in severe cases of perioral dermatitis. These medicines include tetracycline, doxycycline and others.
We have no idea why this treatment approach works since we have no idea why perioral dermatitis develops.
These are the most time-tested treatments for perioral dermatitis.
In my 30+ years of practicing dermatology and treating many people with perioral dermatitis, this approach consistently works. I have never needed to resort to some of the other treatments described in the medical literature which include: photodynamic therapy, isotretinoin and pimecrolimus. These treatments are either potentially dangerous and/or irritating options for this condition.
Does perioral dermatitis come back?
Yes, there perioral dermatitis has a high recurrence rate. But it is often not for a year or two after the skin has cleared. This means that some people are prone to perioral dermatitis, especially young adult women.
To maintain remission, I typically have my dermatology patients continue using their anti-yeast medicine and topical antibiotic for two to four months after the rash has cleared. We then gradually taper off the antibiotic, followed by the anti-yeast medicine over another month or two.
At the first signs of recurrence, we resume the use of these topical medicines as a prevention.
We often use Calming Zinc Soap once a day to wash the face. This soap is fortified with pyrithione zinc, an ingredient known to help fight skin yeast. I have people apply Green Tea Antioxidant Skin Therapy after washing twice daily. These two products are found in my Redness Relief Kit.
Other medicines reported to help include adapalene and azelaic acid. Again, I have not needed to use these potentially-irritating medicines.
At times, I have had patients also use permethrin cream nightly for a week every month to control demodex mites. This is an entirely off-label use of this medicine designed to treat scabies.
Soolantra is another medicine for demodex mites, but it is very expensive, and that makes it unpopular in my practice. Pimicrolimus has been reported to help maintain remissions, but as mentioned above, in my experience, I don’t find it necessary to use this medicine to treat perioral dermatitis.
Andrews’Diseases of the Skin: Clinical Dermatology, Twelfth Edition
Maeda A, Ishiguro N, Kawashima M. The pathogenetic role of rod-shaped bacteria containing intracellular granules in the vellus hairs of a patient with perioral dermatitis: A comparison with perioral corticosteroid-induced rosacea, .Australas J Dermatol. 2016 Aug;57(3):225-8. doi: 10.1111/ajd.12344. Epub 2015 Apr 20.
Ljubojević S, Lipozencić J, Turcić P. Perioral dermatitis. Acta Dermatovenerol Croat. 2008;16(2):96-100.