Perioral dermatitis

• Frumess and Lewis, 1957
• Mihan and Ayres, 1964

Dermatitis perioralis, rosacea-like dermatitis, stewardess disease, periorificial dermatitis.

Reactive disease of the face, rosacea type. Itchy to painful skin changes on the face. Not infectious.

• Incidence: approx. 1%/y.
• Peak in age: 20-40 y.
• Women >> men.
• Professions with make-up compulsion more often affected ("stewardess disease")

None.

• Caused by excessive use of skin care products, cosmetics, sun creams
• Predisposed individuals include atopics
• Vicious cycle when using topical glucocorticoids
• UV light (is not a sole trigger, but can lead to worsening)

The disease is close to rosacea, but the distribution is different. The skin changes are always found around an orificium: perioral, perinasal and/or periorbital erythematous, often grouped, pruritic to burning, confluent, often slightly scaly papules, papulovesicles and pustules, sometimes also thin plaques.

• Clinical picture
• No laboratory tests necessary
• In case of doubt, trial excision

• Perioral, periocular, perinasal
• Regular recess of about 1-2 mm of the skin directly adjacent to the orificium, because there are no vellus hair follicles in this zone, but they are necessary for follicular-bound disease

Follicular centred pathology. Epidermis spongiotic, lymphocytic perivascular infiltrates around follicular ostia. No demodex mites, telangiectasias, actinic elastosis as in rosacea.

If possible, abstain from facial care products.

• Only when patients acknowledge the trigger does improvement occur
• Frequently protracted
• Poor adherence to cosmetic abstinence leads to recurrence

General measures

• Null therapy!
• No cosmetics, no perfumes, no creams or ointments
• Tarbs several times a day for the inflammation in the form of black tea compresses (actually evidence-based. Black tea, not Earl Grey with bergamot oil, steep for 10min, then place wash cloth lukewarm on face for 10min).

Cleansing:

• Mild syndets

Topical therapy:

• Pimecrolimus cream 1% 2x tgl. for 2 weeks
• Azelaic acid gel 1-2x tgl. (may irritate)
• Metronidazole gel 2x tgl.
• Ivermectin cream 1x tgl. (so far off-label)

Make up:

• Only if absolutely necessary for patients
• Mineral concealers without oils

Topical steroids:

• Only in weaning phase after highly potent steroids
• Hydrocortisone 0.5% 1x tgl. for a few days

Systemic antibiotics:

• Doxycycline p.o. 100 mg 2x tgl. for 14-21 days
• Minocycline p.o. 50 mg 2x tgl.

Systemic retinoids:

• Isotretinoin p.o. 10.30 mg 1x tgl.

1. Frieden IJ. Granulomatous Perioral Dermatitis in Children. Arch Dermatol 1989;125:369.
2. Hafeez ZH. Perioral dermatitis: an update. International Journal of Dermatology 2003;42:514-7.
3. Takiwaki H, Tsuda H, Arase S, Takeichi H. Differences between intrafollicular microorganism profiles in perioral and seborrhoeic dermatitis. Clin Exp Dermatol 2003;28:531-4.
4. Dirschka T, Tronnier H, Folster-Holst R. Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis. Br J Dermatol 2004;150:1136-41.
5. Wilkinson DS, Kirton V, Wilkinson JD. Perioral dermatitis: a 12-year review. British Journal of Dermatology 2006;101:245-57.
6. Weston WL, Morelli JG. IDENTICAL TWINS WITH PERIORAL DERMATITIS. Pediatric Dermatology 2009;15:144-.