Overview 

Perioral Dermatitis is a benign (non-harmful) skin disorder that resembles acne or rosacea, occurring most commonly in young people assigned female at birth (AFAB).¹ In the term “perioral”, “peri”means around, with “oral” referring to the mouth. Therefore, perioral dermatitis refers to a skin condition around the region of the mouth. It is characterized by small inflammatory papules (raised areas of skin measuring less than 1cm in diameter) and pustules (pus-filled bumps) or scaly patches around the mouth.¹ Whilst it most commonly affects the region of skin around the mouth, it can also affect the regions around the eyes and nose. Therefore, it is sometimes referred to as periorificial dermatitis.¹ Within this article, we will discuss the symptoms, causes, diagnosis, and treatment so that we can provide a comprehensive understanding of this condition. 

Symptoms and Presentation

As previously discussed, perioral dermatitis presents with an array of presentations on the skin. These different presentations are known as “skin lesions” and are present on both sides of the face in perioral dermatitis. Important to note is that each of these skin lesions are surrounded by regions of redness, otherwise known as areas of “erythema”. The region of erythema is prevalent throughout all cases, and is often indicative of perioral dermatitis. There are numerous different types of skin lesions which characterize perioral dermatitis, and these are known as: 

• Erythematous Follicular Papules²
  • Inflamed, raised regions of the skin that are no larger than 1cm in diameter. These are mainly restricted to the perioral region. 
  • The ‘follicular’ aspect refers to their exact location within the skin. In the instance of perioral dermatitis, papules most commonly tend to occur in the areas of the skin where hair follicles emerge or exist. 
• Pustules²
  • Pus-filled bumps, common to those suffering with perioral dermatitis. These are also mainly restricted to the perioral region. 
• Vesicles¹
  • Raised bumps of the skin containing clear-fluid. They are typically referred to as small ‘blisters’ of the skin. 
• Scaling and/or Flaky Skin¹
  • Area of desquamation over an erythematous basis, often seen as scaling or flaking in those patients with perioral dermatitis. 
• Burning, Itching or Sensitivity¹
  • Some patients report the sensations listed above as being associated with the skin affected in perioral dermatitis. 
• Sparing of Skin Around the Lips¹
  • Patients may also notice that a small, encircling region of skin located immediately next to the lips is often spared.

Whilst the symptoms above involve those that are common to perioral dermatitis, there are some uncommon symptoms which patients should remain vigilant for. These include spreading of the symptoms to the ear, scalp, neck, trunk, vulva, and the extremities.¹ Some people may also experience conjunctivitis in tandem with the development of perioral dermatitis. 

Causes and Risk Factors

Whilst the exact causes of perioral dermatitis remain unknown, numerous risk factors predisposing to its development have been identified. These risk factors are as follows: 

• Use of Topical Corticosteroids¹
  • In many patients, there is an association between the use of topical steroids and the development of perioral dermatitis. Use of topical corticosteroids has been observed to precede the development of the condition, with withdrawal of its use resulting in its appearance. 
  • On the other hand, use of topical corticosteroids may initially improve the symptoms of perioral dermatitis. However, upon withdrawal of these, the condition will reappear and may therefore lead to topical corticosteroid dependency. 
  • Perioral dermatitis has also been reported to occur in those patients who use nasal and inhaled corticosteroids. 
• Infectious Sources¹
  • Some researchers have proposed there to be some infectious causes of perioral dermatitis. These infections include the likes of candida albicans, fusiform bacteria and, and Demodex mites. 
• Fluorinated Toothpaste
  • The use of fluorinated toothpaste has also been associated with predisposing patients to the development of perioral dermatitis. 
• Chewing Gum and Dental Fillings¹
  • The use of chewing gum and need for dental fillings has been identified as another risk factor to the development of perioral dermatitis. 
• Cosmetic Product Use¹
  • The use of certain cosmetic products, such as the use of moisturizers, foundations and sunscreens has also been identified as a risk factor for the development of perioral dermatitis.
• Hormonal Causes¹
  • Given its predominance in AFAB people , hormonal influences have been linked to causing perioral dermatitis.
  • Use of the oral contraceptive pill has shown to be beneficial in the improvement of symptoms associated with perioral dermatitis. 

Diagnosis 

The diagnosis of perioral dermatitis is often a clinical one, meaning it is often diagnosed without the need for invasive tests. In general, there won’t be a laboratory abnormality. Your healthcare provider will often examine the face and area of skin affected by the symptoms previously described. In addition to this, your healthcare provider may also ask you a series of questions relating to the duration and symptoms of the condition. These questions can typically involve asking: 

• For how long have you had the rash/symptoms? 
• When did you first notice this rash or these symptoms? 
• Have you noticed anything that seems to make it better or worse? 
• Do you use any topical steroids or inhaled steroids? 
• Does the area of skin affected itch, burn, or feel more sensitive than usual? 
• Do you have any other types of skin conditions? 
• Do you see a dermatologist for any issues? 

In some instances, your symptoms may not align with the typical symptoms of perioral dermatitis. In this case, your healthcare professional may perform a skin biopsy.¹ This will allow them to distinguish between other skin conditions such as atopic dermatitis. If an infectious cause is suspected, your healthcare professional may also collect microbial cultures. This will allow them to identify the causative infection and thus tailor treatment appropriately. 

Nevertheless, laboratory tests such as prick testing and specific immunoglobulin E testing are not done routinely as, in most cases, there won’t be alterations.³

Treatment

There are numerous treatments associated with perioral dermatitis. The following treatment options are as follows:¹

• Metronidazole cream or gel 
• Clindamycin lotion or gel
• Erythromycin gel 
• Topical sulfur preparations 
• Azelaic acid gel 
• Topical calcineurin inhibitors such as tacrolimus ointment or pimecrolimus cream 
• Photodynamic therapy using 5-aminolevulinic acid

If these therapies are not useful in reducing the symptoms of perioral dermatitis, oral antibiotics are often the next step. These include:¹

• Tetracycline 
• Doxycycline 
• Minocycline 

It is also important that those affected by perioral dermatitis stop the following things to prevent worsening of their symptoms:¹

• Use of topical corticosteroids and inhaled corticosteroids 
• Moisturizers and foundations 
• Cosmetics 
• Fluoride Toothpaste
• Chewing Gum
• Sunscreen 

Other than the medical and behavioral approaches, in some cases, psychological help must be necessary as some patients have increased difficulty to stop using steroids due to dependency to the medications.⁴

Summary

Perioral dermatitis is a skin condition closely resembling that of acne or rosacea. Most commonly affecting the area around the mouth, the condition can often spread to the areas around the eyes and the nose. It is known to affect young AFAB people  the most. Perioral dermatitis is characterized by the presence of papules and pustules, with some patients experiencing the presence of vesicles. The skin affected is reddish in color, with some patients experiencing scaling or flaking of the affected skin. The use of topical or inhaled corticosteroids has been linked as a common risk factor for the development of the condition. Use of cosmetic products, moisturizers and foundations, fluoride toothpaste and chewing gum have all also been identified as risk factors for the development of perioral dermatitis. Diagnosis is largely clinical, with the need for skin biopsies only when the cause of symptoms remains ambiguous. Treatment is largely focused on the use of topical creams and lotions, with the use of oral antibiotics for persistent symptoms that are not responsive to treatment. 

FAQs

Can perioral dermatitis be cured?

Whilst there are numerous treatments available for the treatment of perioral dermatitis, the condition could affect you for several months, if not years. It is common for the rash to appear and disappear sporadically, and so awareness of your personal habits which may cause it to appear is essential. 

When should I see a dermatologist?

If you notice your rash spreading and becoming more painful, then you should contact a dermatologist. Furthermore, if withdrawal from topical corticosteroids does not cause the rash to disappear or instead worsens it, you should contact a dermatologist.