Periorificial dermatitis

What is periorificial dermatitis?

Periorificial dermatitis is a common facial skin problem characterised by groups of itchy or tender small red papules. It is given this name because the papules occur around the eyes, the nostrils, the mouth and occasionally, the genitals.

The more restrictive term, perioral dermatitis, is often used when the eruption is confined to the skin in the lower half of the face, particularly around the mouth. Periocular dermatitis may be used to describe the rash affecting the eyelids.

See more images of perioral, periocular and periorificial dermatitis ...

Who gets periorificial dermatitis?

Periorificial dermatitis and its variants mainly affect adult women aged 15 to 45 years. It is less common in men. It may affect children of any age.

People with periorificial dermatitis are often using topical or inhaled corticosteroids.

What is the cause of periorificial or periorificial dermatitis?

The exact cause of periorificial is not understood. Periorificial dermatitis may be related to:

• Epidermal barrier dysfunction
• Activation of the innate immune system
• Altered cutaneous microflora
• Follicular fusiform bacteria

Unlike seborrhoeic dermatitis, which can affect similar areas of the face, malassezia yeasts are not involved in periorificial dermatitis.

Periorificial dermatitis may be induced by:

• Topical steroids, whether applied deliberately to facial skin or inadvertently
• Nasal steroids, steroid inhalers, and oral steroids
• Cosmetic creams, make-ups and sunscreens
• Fluorinated toothpaste
• Neglecting to wash the face
• Hormonal changes and/or oral contraceptives

What are the clinical features of periorificial dermatitis?

The characteristics of facial periorificial dermatitis are:

• Unilateral or bilateral eruption on chin, upper lip and eyelids in perioral, perinasal and periocular distribution
• Sparing of the skin bordering the lips (which then appears pale), eyelids, nostrils
• Clusters of 1–2 mm erythematous papules or papulopustules
• Dry and flaky skin surface
• Burning irritation

In contrast to steroid-induced rosacea, periorificial dermatitis spares the cheeks and forehead.

Genital periorificial dermatitis has a similar clinical appearance. It involves the skin on and around labia majora (in females), scrotum (in males) and anus.

Complications of periorificial dermatitis

Granulomatous periorificial dermatitis is a variant of periorificial dermatitis that presents with persistent yellowish papules. It occurs mainly in young children and nearly always follows the use of a corticosteroid. There is a granulomatous perifollicular infiltrate on histopathology.

Steroid rosacea presents with steroid-induced, large facial papules, papulopustules and telangiectasia on the mid-face, including forehead and cheeks.

Rebound flare of severe periorificial dermatitis may occur after abrupt cessation of application of potent topical steroid to facial skin.

How is periorificial dermatitis diagnosed?

The presentation of periorificial dermatitis is usually typical, so clinical diagnosis is usually straightforward. There are no specific tests.

Skin biopsy shows follicular and perivascular chronic inflammation similar to rosacea.

What is the treatment for perioral dermatitis?

Periorificial dermatitis responds well to treatment, although it may take several weeks before there is noticeable improvement.

General measures

• Discontinue applying all face creams including topical steroids, cosmetics and sunscreens (zero therapy).
• Consider a slower withdrawal from topical steroid/face creams if there is a severe flare after steroid cessation. Temporarily, replace it by a less potent or less occlusive cream or apply it less and less frequently until it is no longer required.
• Wash the face with warm water alone while the rash is present. When it has cleared up, use a non-soap bar or liquid cleanser if you wish.
• Choose a liquid or gel sunscreen.

Topical therapy

Topical therapy is used to treat mild periorificial dermatitis. Choices include:

• Erythromycin
• Clindamycin
• Metronidazole
• Pimecrolimus
• Azelaic acid

Oral therapy

In more severe cases, a course of oral antibiotics may be prescribed for 6–12 weeks.

• Most often, a tetracycline such as doxycycline is recommended. Sub-antimicrobial dose may be sufficient.
• Oral erythromycin is used during pregnancy and in pre-pubertal children.
• Oral low-dose isotretinoin may be used if antibiotics are ineffective or contraindicated.

How can periorificial dermatitis be prevented?

Periorificial dermatitis can generally be prevented by the avoidance of topical steroids and occlusive face creams. When topical steroids are necessary to treat an inflammatory facial rash, they should be applied accurately to the affected area, no more than once daily in the lowest effective potency, and discontinued as soon as the rash responds.

What is the outlook for periorificial dermatitis?

Periorificial dermatitis sometimes recurs when the antibiotics are discontinued, or at a later date. The same treatment can be used again.