Overview
Definition:
Perioral dermatitis is a common inflammatory facial dermatosis characterized by small papules, pustules, and erythema primarily around the mouth, sparing a narrow zone of uninvolved skin at the vermilion border of the lips
In children, it often presents as a milder variant.
Epidemiology:
While more common in young to middle-aged women, perioral dermatitis can occur in children, particularly in prepubertal and adolescent age groups
The exact incidence in pediatric populations is not well-defined but is considered relatively uncommon compared to adults.
Clinical Significance:
Perioral dermatitis in children, though often benign, can cause significant cosmetic concern and emotional distress for the child and parents
Accurate diagnosis and management are crucial to prevent scarring and psychosocial impact, and to distinguish it from other more serious facial eruptions.
Clinical Presentation
Symptoms:
Mild burning or itching sensation
Redness and small bumps around the mouth
Sometimes, dryness or peeling skin is noted
Parents may report new onset of a rash.
Signs:
Erythematous papules and pustules, often clustered
Typically spares a narrow zone (1-2 mm) immediately adjacent to the vermilion border
May involve the nasolabial folds and periorbital areas in some cases
No significant comedones or significant scaling.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the characteristic distribution of papules and pustules around the mouth, with relative sparing of the vermilion border
Absence of typical acne features like comedones is important.
Diagnostic Approach
History Taking:
Inquire about recent application of topical corticosteroids (especially potent ones) to the face, use of certain facial moisturizers or cosmetics, dental products, and any history of nasal regurgitation or chronic drooling
Ask about duration and progression of the rash
Rule out other facial rashes.
Physical Examination:
Examine the entire face, paying close attention to the perioral area, nasolabial folds, and periorbital regions
Document the morphology (papules, pustules, erythema) and distribution of lesions
Assess for comedones to differentiate from acne vulgaris
Evaluate for scaling or xerosis.
Investigations:
Typically, no investigations are required for the diagnosis of perioral dermatitis in children
If there is any suspicion of fungal infection (e.g., tinea faciei), a KOH preparation or fungal culture may be considered
Biopsy is rarely indicated but can show superficial perivascular dermatitis with granulomas in some cases.
Differential Diagnosis:
Acne vulgaris (presence of comedones)
Impetigo (honey-colored crusts, usually contagious)
Contact dermatitis (history of exposure to irritant or allergen, more pruritic)
Atopic dermatitis (generalized dryness, itching, flexural involvement)
Rosacea (rare in children, typically involves telangiectasias, flushing)
Tinea faciei (ringworm, annular lesions with central clearing).
Management
Initial Management:
Discontinuation of precipitating topical corticosteroids is the cornerstone of treatment
Educate parents about the nature of the condition and the rationale for treatment
Reassurance that the condition is treatable.
Medical Management:
Topical treatments are preferred in children: Topical metronidazole (0.75% or 1%) gel or cream twice daily for several weeks
Topical erythromycin (2%) gel or solution twice daily
Topical azelaic acid (15%) cream
Oral antibiotics: Erythromycin (30-50 mg/kg/day divided in 2-3 doses) or tetracycline (if >8 years old, 25-50 mg/kg/day divided in 2-3 doses) may be used for more severe or persistent cases, typically for 4-8 weeks
Isotretinoin (oral retinoid) is reserved for severe, recalcitrant cases and requires close monitoring due to potential side effects.
Surgical Management:
Surgical management is not indicated for perioral dermatitis.
Supportive Care:
Gentle cleansing of the face with mild, non-perfumed cleansers
Avoid harsh scrubbing
Use bland emollients or moisturizers if dryness is prominent
Educate parents to avoid potent topical steroids on the face.
Complications
Early Complications:
Temporary worsening of rash after initiation of treatment, especially with oral antibiotics
Development of side effects from medications (e.g., gastrointestinal upset with oral antibiotics, skin irritation with topicals).
Late Complications:
Recurrence of the rash is common, especially if trigger factors are not identified and avoided
Scarring is rare but can occur with severe inflammation or secondary infection
Psychological distress due to persistent facial lesions.
Prevention Strategies:
Educate parents and caregivers on the judicious use of topical corticosteroids, especially on the face
Advise avoidance of potentially irritating facial products
Prompt treatment of any initial papulopustular eruption around the mouth.
Prognosis
Factors Affecting Prognosis:
Prompt diagnosis and adherence to treatment, avoidance of precipitating factors (especially topical steroids), and severity of initial presentation influence prognosis
Younger age may sometimes be associated with quicker resolution.
Outcomes:
With appropriate treatment, perioral dermatitis in children generally resolves well, often within several weeks to months
However, recurrences are possible
Complete clearance of lesions is the usual outcome.
Follow Up:
Follow-up is recommended after 4-8 weeks of treatment to assess response
If lesions persist or worsen, re-evaluation and adjustment of treatment are necessary
Long-term follow-up may be needed for patients with recurrent disease to manage trigger factors.
Key Points
Exam Focus:
Key feature: papulopustular eruption around the mouth sparing the vermilion border
Most common trigger: topical corticosteroids
Management: topical metronidazole/erythromycin, oral antibiotics for severe cases
Avoid potent topical steroids.
Clinical Pearls:
Always ask about topical steroid use
Reassure parents that this is not acne, although it may look similar
Treatment can take several weeks to show full effect
Careful explanation to parents is crucial for adherence.
Common Mistakes:
Prescribing potent topical corticosteroids for what appears to be perioral dermatitis initially, which will worsen the condition
Misdiagnosing it as acne vulgaris and treating inappropriately
Not inquiring about topical steroid use as a crucial part of history.