Treating Perioral Dermatitis: How to Tell if It Is Getting Better

Have you ever had red, irritating bumps on the lower half of your face? Acne and allergic reactions are often the first possible causes we think of as a primary cause. But what if it’s something else? And what if the treatment you're using is making it worse? Perioral dermatitis, a common skin condition primarily affecting women and children, is frequently misdiagnosed, even by physicians. Understanding what perioral dermatitis is, what it looks like, and the underlying mechanism can help distinguish it from other conditions and make it easier to manage.

What is perioral dermatitis?

Perioral dermatitis is an inflammatory skin condition affecting the skin around the mouth. Other forms of the same disorder that fall under the umbrella term 'periorificial dermatitis' include periocular dermatitis, present around the eyes, and perinasal dermatitis, which occurs around the nose. Perioral dermatitis can present differently in each individual and may mimic other skin conditions, such as acne, rosacea, and eczema.

This rash often appears as small, red, acne-like breakouts in individuals with lighter skin tones and as skin-colored breakouts in those with darker skin tones.

Perioral dermatitis

What are the symptoms of perioral dermatitis?

Perioral dermatitis is often uncomfortable, not only because of the appearance but also due to underlying tissue inflammation. Symptoms of perioral dermatitis may include:

  • Small, round, raised lesions that are similar in size. The lesions may be a few or numerous (resembling a facial rash)
  • Dryness and flaking of the lesions and surrounding skin
  • Redness
  • Burning sensation
  • Itching
  • Tightness and tenderness
  • Sparing of the skin near the border of the lip

How is perioral dermatitis treated?

The treatment of perioral dermatitis may differ slightly for everyone, depending on the cause or trigger and severity of the condition.

Discontinuation/avoidance of irritant

If the trigger is determined to be the long-term use of corticosteroid cream or a new cosmetic product, it should be discontinued. Lifestyle triggers, such as increased stress and exposure to pollution, must be managed to reduce risks.

Topical therapy

Topical therapy is often used first to minimize the risk of side effects. There is currently no standardized treatment guideline for perioral dermatitis. The choice of therapy is decided based on the severity of the disease, possible triggers and risk factors, and tolerability of the medication. Topical treatment options for perioral dermatitis include:

  • Metronidazole
  • Topical antibiotics, including clindamycin and erythromycin
  • Azelaic acid
  • Topical calcineurin inhibitors, such as tacrolimus and pimecrolimus
  • Adapalene

Although it may provide relief from the inflammation, topical corticosteroids should not be used in perioral dermatitis, even when it is triggered by something else.

Oral medications

Oral medications may be used in more severe cases when topical therapy is insufficient:

  • Oral antibiotics, such as doxycycline, tetracycline, and minocycline
  • Low-dose oral isotretinoin

The choice of drug is determined by age and other factors influencing the tolerability of the medication.

Natural remedies

Although you may have read of some using natural products found in our kitchens and gardens to treat their perioral dermatitis, there is currently no clinical research available supporting the use of natural remedies to treat perioral dermatitis. However, based on research available on the effect of some natural products on skin function, the following natural remedies may provide future treatment options.

As these natural products have not been studied to determine effective doses and potential side effects in perioral dermatitis and may contain contaminants that irritate the skin, more research is needed before they are used in treatment. Please speak with your physician before using any natural remedies to treat perioral dermatitis.

Skincare and cosmetics

Certain skincare, such as heavy creams, can overly hydrate and congest the skin. This can disrupt the normal function of the skin barrier and lead to inflammation. Other cosmetics, such as foundation and sunscreen, can also cause skin congestion and irritation. Due to this, some patients with perioral dermatitis may find it triggered by using new skincare and cosmetic products.

However, maintaining appropriate skin hydration levels is also critical to the health of the skin barrier. Self-care with good skin hygiene, such as using a mild face wash followed by a serum or light lotion, is usually recommended. If tretinoin and antibiotics have been prescribed, the skin can be more sensitive to the sun, and perioral dermatitis may worsen when exposed to UV rays. Gel-based sunscreens may not trigger or worsen perioral dermatitis while protecting the skin. However, the use of sun-protective clothing and hats, as well as avoiding direct sunlight, is recommended.

Diet

No special diet is recommended for the treatment of perioral dermatitis. However, what we eat affects the microbiome of our gut and skin and provides nutrition for the proper functioning of all organ systems.

Zinc is vital in the normal development and functioning of skin tissue. Deficiencies in zinc have led to perioral dermatitis in infants requiring supplementation for resolution. However, there is no evidence showing that extra zinc supplementation will treat perioral dermatitis. To ensure optimum skin and immune system health, a well-rounded diet is essential.

While there is no direct link, food allergies may trigger perioral dermatitis due to the activation of the immune system. Keeping a food and activity diary can help identify potential triggers.

Light therapy

Red light therapy may be helpful as an adjuvant treatment for perioral dermatitis due to its wound-healing properties and low risk of side effects. However, no research has been published assessing the use of red light therapy for perioral dermatitis.

Please speak to your dermatologist before using red light therapy if you have perioral dermatitis.

How do I know that my perioral dermatitis is healing?

The course of disease and healing of perioral dermatitis lesions follows the natural progression of the stages of wound healing.

  1. Initial treatment response corresponds with the first three stages of wound healing, during which signals for new cell growth are released and new cells start to form. This response begins immediately after the removal of the trigger and start of treatment and may last from 2–4 weeks. Symptoms may appear worse initially, especially if the discontinued trigger is a steroid. However, symptoms will start to settle, with a decrease in inflammation and lesions. As the new, healthy tissue grows, there may be flaking due to the shedding of the old skin. It is essential to continue treatment at this point as the skin is vulnerable to damage.
  2. Visible healing is evident when the skin cells continue to grow and mature. During weeks 3–7, new layers of the skin form, and collagen starts to be replaced in the dermis (the second main layer of the skin). The skin may seem to be clearer, and the lesions would have visibly decreased. Any hyperpigmentation (dark spots) caused by the inflamed lesions will lighten but may not disappear completely.
  3. Resolution and long-term management of the new skin begins once the wound is closed and the upper layers of the damaged skin have been replaced. Structural support of the skin is improved and any extra collagen is removed, causing skin contraction. This process improves the strength of the skin and makes it more resistant to damage. The improvement of post-inflammatory hyperpigmentation will become more apparent, and the skin barrier will also become more robust. This phase may last over a year.

How long does perioral dermatitis take to heal?

The complex nature and multifactorial causes of perioral dermatitis result in varying disease courses between individuals. In some cases, avoiding what triggered the outbreak can stop the disease activity, and healing may be completed in 4–6 weeks. In other cases, treatment may be needed, and lesions may heal in a few weeks or up to a few months. In severe cases of perioral dermatitis, there is no resolution of the disease even with treatment. Instead, there may be a cyclical recurrence of symptoms that will require management with medications and lifestyle modifications.

What causes perioral dermatitis?

Disruption of healthy skin function, such as changes in skin structure, microbiome (helpful microorganisms that usually live on our skin), hydration levels, and the overuse of emollients, are thought to increase the risk of developing perioral dermatitis. The exact cause is not yet elucidated. However, perioral dermatitis is considered a multifactorial disease influenced by several risk factors and triggers.

Can steroids cause perioral dermatitis?

The prolonged use of corticosteroids in creams, sprays, and nebulizers for asthma and seasonal allergies, as well as oral corticosteroids, has been associated with perioral dermatitis. Several mechanisms are thought to be involved. Steroids possess immunosuppressive properties, which can decrease certain immune cells in the area and influence the composition of the local microbiome.

Although topical steroids are used in eczema to help control a disordered immune response, prolonged use can cause topical skin withdrawal (TSW). This severe inflammatory reaction occurs in the area of steroid application once discontinued. TSW was once thought to be the primary cause of perioral dermatitis. However, perioral dermatitis can occur without a history of steroid use.

Impaired skin barrier function in perioral dermatitis

The skin barrier comprises skin cells, connective tissue, various proteins, water, fat molecules, and immune cells. It keeps irritants and harmful microbes out while keeping the water molecules in the epidermis (outer layer of the skin) in. Impairment in the skin barrier increases water loss, dehydrating the skin while allowing potential irritants to enter and increase inflammation. The skin of the chin and folds in the skin (e.g., smile lines) have a weaker barrier function and are more sensitive to external irritants in patients with perioral dermatitis.

Risk factors of perioral dermatitis

Several internal and external triggers increase the risk of perioral dermatitis through a combination of the mechanisms described above.

  • Hormonal fluctuations, such as during the menstrual cycle
  • Stress
  • Environmental changes
  • Face masks, as seen with protective masks during the COVID-19 pandemic and improper use of continuous positive airway pressure (CPAP) masks.
  • Moisturizers and sunscreens
  • Fluorinated toothpaste
  • Cosmetics

What are the consequences of untreated perioral dermatitis?

In many cases, untreated perioral dermatitis may resolve on its own, especially if the trigger is removed. However, if there is no improvement in symptoms and signs of healing are not seen within 4–6 weeks, the skin is vulnerable to additional damage. This may result in more inflammation and lesions but also increases the risk of infection, leading to acne-like lesions or more severe conditions, such as impetigo. To mitigate this risk, it is imperative to seek consultation with a dermatologist to ensure a correct diagnosis and provide the appropriate treatment.

Perioral dermatitis is caused by the interplay of several internal and external factors that cause changes in the skin, leading to inflammatory eruptions. The presentation of perioral dermatitis can vary greatly and include redness, burning, and skin flaking, mimicking other, more well-known skin issues, such as acne and eczema. Misdiagnosis and delayed diagnosis can lead to inappropriate treatment with steroids, which worsen the symptoms and increase the risk of future recurrence through damage to the skin barrier. Other triggers, such as using heavy emollients, irritants in cosmetics, and pollution, can also trigger an outbreak. To ensure proper diagnosis and management, it is essential to seek the help of a qualified professional with experience treating perioral dermatitis.

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