Perioral dermatitis is a common, yet curious skin condition that takes it's name from the location. Peri means "around" and of course oral, means "mouth". Therefore, perioral dermatitis is an eruption that is limited to the area surrounding the mouth.

Perioral dermatitis (PD) affects up to 1% of the population, primarily young women ages 25-45. The rash looks like a cross between acne and eczema. PD does tend to affect people differently. Some patients have an appearance more like acne, others more like eczema, and some have equal attributes of both. Basically, acne-like blemishes form within areas that can be red, rough, scaling and very sensitive. Symptoms of itching and burning may also be present.

The Rosacea Dilemma

Is it rosacea or perioral dermatitis? A word of warning, regarding the diagnosis of perioral dermatitis. Occasionally, a new onset of acne rosacea can mimic the appearance of perioral dermatitis. If a patient is unable to be weaned off their medication, I will seriously consider the former diagnosis.

Why Me?

Since PD is far more common in developed countries; it is thought that the environment is somehow involved. Combine that with the fact that an overwhelming number of PD patients (90%) are women, and cosmetics and toiletry use have naturally been implicated. Here's a list of potential cosmetic ingredients one may want to consider avoiding if affected by PD:

• Petrolatum
• Paraffin
• Flourinated Toothpaste
• Sodium Lauryl Sulfate
• Isopropyl Myristate
• Cinnamon Flavoring (Oral care products, candies and gum)
• Tartar Control Ingredients

There is no guarantee that avoiding these ingredients in your cosmetics and grooming supplies will automatically "cure" you of perioral dermatitis. But it may be worthwhile to try a skin "elimination diet" to rule them out as a possible flare factor. One suggestion is to try Squigle which is free of ingredients suspect in causing PD.

A study published in the Australasian Journal of Dermatology evaluated the affects that cosmetics and skin care products had in causing perioral dermatitis. The use of a solo moisturizer did not increase the risk of developing PD. However, the addition of a night cream and wearing daily foundation caused a 13 fold increased risk of getting perioral dermatitis.

Skin Addiction

Many perioral dermatitis patients have already been seen by another physician long before they ever make it in to see the dermatologist. The most frequent choice of therapy by a non-dermatologist for this disorder is a very high potency topical steroid. Yes, it will work initially. But just try to stop using it. Each time it's withdrawn, the rash flares up, often worse than it was before.

The reason: the skin literally becomes addicted to these high potency topical steroids. That makes it extremely difficult for a dermatologist to convince the patient to give the treatment up. It's not that most patients haven't tried to stop. But whenever it was attempted, the condition rebounded.

Besides miring you in this chronic cycle, regular use of a high-potency topical steroid can lead to atrophy (thinning) of facial skin. And atrophy can lead to lightened skin, spider veins and stretch marks. So if you have perioral dermatitis, it is really in your best interest to give up the offending cream. Once you stop the cream, my counsel is to wait out the rebound - it will last approximately 2 weeks. If at the same time you start appropriate PD therapy, you'll see a reduction in the intensity of the rebound.

PD THERAPY

My typical PD regimen typically lasts six weeks. At that time, I reevaluate the patients. If her skin is clear, I gradually reduce the amount of medication used as well as the frequency of the dosing. In other words, I wean the patient off therapy. This helps prevent the rash from rebounding. While every patient's needs are different, the average time frame for weaning is 2-4 weeks.

Tx Plan:

• Oral Therapy

  The systemic use of antibiotics dramatically helps clear the blemishes associated with PD. And remember, since the skin is likely sensitive, harsh topical acne medications are often drying and irritating. Oral tetracycline, minocycline or doxycycline are preferred. For patients unable to take these medications or who may be pregnant or nursing, oral erythromycin or a form of penicillin can be considered.

• Topical Steroids

  What?! Didn't I just get done lecturing about avoiding topical steroids? Well, yes and no. Potent topical steroids are bad for the skin. Very mild topical steroids can help reduce local inflammation, help control the PD and make any rebound reaction tolerable. I often prescribe very weak topical steroids like Desowen Lotion or Westcort Cream. An OTC option would be plain 1% hydrocortisone cream, such as Cortaid Advanced Maximum Strength Cream.

• Topical Immunomodulators

  Can't handle the topical steroids or they simply aren't helpful? The short term use of Protopic or Elidel can target the eczematous component of the perioral dermatitis and spare the skin further steroid use.

• Topical Cleansers

  Usually, it's quick and easy to go for a simple gentle cleanser such as Cetaphil Gentle Skin Cleanser. However, the anti-yeast action of a pyrithione zinc cleanser such as DERMAdoctor Born To Be Mild Medicated Face & Body Cleanser, or the prescription ketoconazole product Nizoral 2% Shampoo may be beneficial. They help kill the yeast and Demodex parasites which may complicate and contribute to the formation of PD.

• Make-Up

  It's time to shelve the make-up. Yes, it's very hard to go to work, school, parties, etc. sans make-up, but it's the very best thing you can do for your skin right now. Until the perioral dermatitis is fully gone, try to grin and bear it.

• Make Sun Protection A Must

  Ultraviolet light, heat and wind are thought to make PD look worse. Apply a broad spectrum SPF 30 every day. Should you have an issue with chemical sunscreen ingredients, try a physical blocker (one based solely upon titanium dioxide or zinc oxide) and make sure it's fragrance free. Try Vanicream Sunscreen Sensitive Skin SPF 60 or Obagi Nu-Derm Physical UV Block SPF 32.

• Moisturize As Needed

  Yes, it's okay to moisturize as long as the cream doesn't contain an offending agent. However, I would skip any extra skin care products if at all possible in order to clarify how the skin is responding (or not) to treatment. In addition to routine moisturizers (read the label, many contain petrolatum), facial moisturizer options can include MD Formulations Critical Care Shielding Creme

• Brush Your Teeth The Right Way

  There are definitely PD patients who are triggered by their oral care products. Make sure they are void of sodium lauryl sulfate (SLS), red dye and cinnamon flavoring. Again, don't forget about trying Squigle Enamel Saver Toothpaste

Getting rid of ring around the mouth is just a ring to your dermatologist away. Get the facts, get in tune with what you may be able to avoid and most definitely get appropriate treatment from your doctor.

Thank you for taking the time to read my newsletter on Perioral Dermatitis. I hope that you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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