4.1.3 Perioral Dermatitis
Grading & Level of Importance: B
Perioral dermatitis; Rosacea-like dermatitis.
In the USA around 0.5 to 1%, no clear data from Europe. Often misdiagnosed.
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.
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.
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.
Perioral, periorbital, nasolabial, glabella. Genital.
Laboratory & other workups
Not necessary. Sometimes bacterial and mycologic swab.
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.
It mostly starts slowly over 2- 3 weeks. Flares can be seen whilst reducing frequency of application of corticosteroid creams.
Granulomatous type of POD.
Sometimes difficult. Case history and localisation important. Exclude comedones and rosacea.
Rosacea of papulo-pustular type. Gram-negative folliculitis. Corticosteroid acne, PRIDE syndrome from oncologic therapy with EGF receptor antagonists.
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.
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