4.1.3 Perioral Dermatitis

Grading & Level of Importance: B

Review:

2026

W. Burgdorf, Munich; S. Chee, A. Salam, J. McGrath, London
Revised by H. Gollnick, Magdeburg

Overview:

ICD-11
Synonyms
Epidemiology
Definition
Aetiology & Pathogenesis
Signs & Symptoms
Localisation
Classification
Laboratory & other workups
Dermatopathology
Course
Complications
Diagnosis
Differential Diagnosis
Prevention & Therapy

ICD-11

ED90.1

Synonyms

Perioral dermatitis; Rosacea-like dermatitis.

Epidemiology

In the USA around 0.5 to 1%, no clear data from Europe. Often misdiagnosed.

Definition

Acneiform dermatosis with small papules and tiny pustules without comedones and with almost exclusively perioral and periorbital involvement. F 70% > 30% M. 20-40 years of age. Increasing number of children and adolescents with POD. The name is deduced from its location of lesions occurring primarily around the mouth but also around the eyes, the nostrils, and occasionally, the genitals.

Aetiology & Pathogenesis

Some evidence exists that a hyperhydration of the follicular epithelium and steroid induced atrophy of the epithelium can support the release of inflammatory mediators into the surrounding superficial dermis and acroinfundibulum.

Long-term use of topical steroid preparations
Daily cosmetics: skin care with high water content ointments and creams incl.sunscreens and fluorinated toothpastes
Physical factors: high humidity
Microbiologic factors: Fusiform spirilla bacteria from the oral microbiome settling in the perioral region. Often induction or worsening after long lasting dental procedures, Malassezia furfur and Candida species can superinfect.

Some evidence exists that a hyperhydration of the follicular epithelium and steroid induced atrophy of the epithelium can support the release of inflammatory meditors into the surrounding superficial dermis and acroinfundibulum.

Long term use of topical steroid preparations is a provocateur. Periorificial dermatitis (POD) has also been reported after the use of nasal steroids sprays and creams or steroid inhalers.
Daily cosmetics: skin care with high water content creams including sunscreens, and an ingredient of the moisturizing vehicle isopropyl myristate are to be causative. Fluorinated toothpastes.
Physical factors: high humidity
Microbiologic factors: Fusiform spirilla bacteria from the oral microbiome settling in the perioral region (saliva excess in the night running from the angulae to the sorrounding skin). Often induction or worsening after long lasting dental procedures, Malassezia furfur and Candida species can superinfect.

Signs & Symptoms

Inflammatory small papules with tiny pustules, erythema and small scales are dominant lesions. The patients often complain of burning and tight sensation. No comedones.

Inflammatory small papules with tiny pustules, erythema and small scales are dominant lesions. The patients often complain of burning and tight sensation. No comedones. Often impaired quality of life.

Localisation

Perioral, periorbital, nasolabial, glabella. Genital.

Classification

None.

Laboratory & other workups

Not necessary. Sometimes bacterial and mycologic swab.

Dermatopathology

Usually not necessary. In granuloma like lesions a biopsy to exclude rosacea, acne agminata or sarcoidosis and histiocytic diseases can become necessary. Mostly perifollicular and dermal edema and prominent lymphomononuclear infiltrates with slight spongiosis of the acroinfundibular and interfollicular sometimes acanthotic epithelium.

Course

It mostly starts slowly over 2- 3 weeks. Flares can be seen whilst reducing frequency of application of corticosteroid creams.

Complications

Granulomatous type of POD.

Diagnosis

Sometimes difficult. Case history and localisation important. Exclude comedones and rosacea.

Differential Diagnosis

Rosacea of papulo-pustular type. Gram-negative folliculitis. Corticosteroid acne, PRIDE syndrome from oncologic therapy with EGF receptor antagonists.

Rosacea of papulo-pustular type.
Gram-negative folliculitis.
Corticosteroid-induced acne, PRIDE syndrome from oncologic therapy with EGF receptor antagonists.
Sometimes a mixture of acne and / or rosacea with POD can be complicated to differentiate.

Prevention & Therapy

Topical: withdraw corticosteroids, however, flare up may occur. Initially slow down corticosteroids to every other day or every third day. Change from strong moisturizer galenics to less water containing ones. Apply initially over night drying zinc lotion. Metronidazole lotion, fucidin cream, topical ketoconazole help to reduce spirilla microbes. Systemic: low dose doxycycline (anti-inflammatory, not for antibiotic effects).

Important point: never use topical corticosteroids as first treatment.

Prevention: Avoid facial use of corticosteroids and of overwashing and overmoisturizing.

Therapy:

Topical: withdraw corticosteroids, however, flare up may occur. Initially slow down corticosteroids to every other day or every third day. Change from strong moisturizer galenics to less water containing ones. Apply initially overnight drying zinc lotion. Metronidazole lotion, fusidic acid cream, topical ketoconazole helps to reduce spirilla microbes. Further for reducing inflammatory course pimecrolimus or tacrolimus.

Systemic: low dose doxycycline (anti-inflammatory, para-antibiotic effect).

Important point: never use topical corticosteroids as a treatment.