Periorificial facial dermatitis

 

Periorificial dermatitis is a term covering two erythematous and papulopustular facial dermatoses that are strongly linked to prolonged potent topical corticosteroid use, namely perioral dermatitis and periocular dermatitis.

 

 

Epidemiology

 

It almost entirely affects young women of 15–25 years of age; perioral dermatitis is now recognized to occur in children as well. The granulomatous form of perioral dermatitis has been reported mostly in children of prepubertal age.

 

 

Pathophysiology

 

A relationship of perioral dermatitis to the misuse of topical corticosteroids (fluorinated or nonfluorinated) has been well established. Patients often reveal a history of an acute steroid-responsive eruption around the mouth, nose, and/or eyes that worsens when the topical corticosteroid is discontinued. Dependency on the use of the topical corticosteroid may develop as the patient repeatedly treats the recurrent eruption. Overuse of cosmetics and moisturizers has also been implicated in exacerbating periorificial dermatitis, and intolerance of sunlight and hot water are common symptoms. There appear to be associations with atopic eczema and with the use of potentially irritant products on the skin: impairment of the skin barrier has been postulated as a further aetiological factor.

 

 

Clinical features

 

The preparation responsible may have been ‘borrowed’ for treating trivial facial blemishes. Most medical practitioners are now fully aware of the hazards of prolonged potent topical steroid use on the face.

 

The most common presentation is clusters of monomorphous superficial pinpoint pustules and/or pink papules, patches and thin plaques, some of which have fine scale. The lesions are often symmetric but may be unilateral and appear in the perioral, perinasal, and/or periocular regions.  Characteristically, the eruption begins abruptly in the nasolabial areas spreading rapidly to the lower face and chin, usually leaving a 5-mm clear zone of unaffected skin around the mouth (mucocutaneous junction) which then appears pale. Pustules on the cheeks adjacent to the nostrils are highly characteristic, and sometimes the disease remains confined to this area. There are no comedones. The more potent the steroid, the more likely it is to result in perioral dermatitis, although it has also been reported with hydrocortisone. Steroids from asthma inhalers and nebulizers have also been implicated.

 

Periocular dermatitis is similar to perioral dermatitis and affects the eyelids and periorbital skin. It usually results from the use of steroid‐containing ophthalmic preparations.

 

In contrast to steroid-induced rosacea, periorificial dermatitis spares the cheeks and forehead.

Granulomatous periorificial dermatitis in children presents with monomorphous pink papules that have become confluent around the mouth.

 

 

Disease course and prognosis

 

Most patients experience permanent remission after a fairly short course of broad-spectrum antibiotics. Relapses occur in a small minority. However, if untreated and especially if the provoking topical steroids are continued, perioral dermatitis can persist for years.

 

 

Treatment

 

The most important measure is to discontinue application of topical corticosteroids. As with other corticosteroid‐induced skin disorders, the substitution of a milder version of topical corticosteroid will diminish the subsequent flare when the more potent preparation is stopped. Other applications, including cosmetics, should be avoided. The patient must be warned that an initial flare is to be expected. A 4‐8week course of an oral doxycycline, minocycline or azithromycin and topical metronidazole is commonly used and is usually effective in clearing the skin. Unlike rosacea, clearance is usually not followed by a subsequent relapse unless the patient is re-exposed to the inciting trigger.

Granulomatous periorificial dermatitis in children resolves with a 6-week course of azithromycin.

 

Steroid-induced rosacea

Is a facial eruption in which erythema, large papules and pustules, and sometimes telangiectasias and atrophy, develop on the mid face, including cheeks and forehead, from the repeated application of moderate to high potent topical corticosteroid preparations to the face. Again, Demodex mites are present in high numbers. Reducing the strength of the topical corticosteroid application rather than its abrupt discontinuation is advisable in order to avoid a rebound flare. Systemic antibiotics (doxycycline, minocycline or azithromycin) are usually required for 4-8 weeks to allow the skin to settle.