Perioral Dermatitis Medication

In severe forms of perioral dermatitis (POD), systemic treatment with antiacne drugs is required. The drugs of choice are doxycycline (or tetracycline) and minocycline. In unresponsive and granulomatous forms, oral isotretinoin^[12] may be considered. In cases with minor presentations, as well as in children and pregnant women, individualized topical therapy is generally recommended. Anti-inflammatory agents (eg, metronidazole^{[6, 13, 14, 15]} and erythromycin) are administered in a nongreasy base (eg, gel, lotion, cream). Pimecrolimus cream significantly reduced the novel Perioral Dermatitis Severity Index^[16] (PODSI) compared with vehicle in a randomized, double-blind study.^[17] Pimecrolimus cream seems to be most effective in steroid-induced perioral dermatitis.^[18] Topical antiacne medications such as adapalene^[19] and azelaic acid^{[20, 21]} have been used in open studies. Ointments should be avoided.

Zero-therapy is based on the idea that by ceasing use all topical medications and cosmetics, the underlying causative factor for perioral dermatitis is eliminated. This form of therapy is appropriate in very compliant patients. It may be effective predominantly in cases associated with steroid abuse or when intolerance to cosmetics is suspected.^{[22, 23]} This therapeutic option is often limited because of the patient's tendency to overtreat his or her condition.

In every case, an initial worsening of the symptoms may occur with treatment, especially if topical steroids are withdrawn. The patient should be made aware of this complication. In cases of preceding long-term abuse of topical steroids, steroid weaning with low-dose 0.1-0.5% hydrocortisone cream can be tried initially.

Class Summary

These drugs may have antibacterial and/or anti-inflammatory effects that are responsible for their effectiveness in perioral dermatitis.

Doxycycline (Bio-Tab, Doryx, Vibramycin)

DOC in nonpregnant women. Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Alternatively, may use tetracycline in adapted dose.

Minocycline (Dynacin, Minocin)

Believed to be most efficacious tetracycline in dermatoses of sebaceous glands. Used to treat infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma species.

Tetracycline (Sumycin)

Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunits. Has anti-inflammatory activity.

Metronidazole (Flagyl)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. In concentrations of 0.75-2%, considered to be DOC in topical treatment of POD. Available in a gel, lotion, or cream. Oral metronidazole has also been used in treatment of perioral dermatitis.

Erythromycin (E.E.S., E-Mycin, Ery-Tab)

Topical erythromycin in concentrations of 2-4% as a gel or cream is an alternative to metronidazole in topical treatment. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Used to treat staphylococcal and streptococcal infections.

Class Summary

These agents reduce the size of the sebaceous glands, decrease sebum secretion, and inhibit keratinization.

Isotretinoin (Accutane)

Oral agent used to treat serious dermatologic conditions. Synthetic 13-cis isomer of naturally occurring tretinoin (trans -retinoic acid). Both agents are structurally related to vitamin A. Decreases sebaceous gland size and sebum production. May inhibit sebaceous gland differentiation and abnormal keratinization. Indicated for long-standing and refractory forms of POD. Because of adverse effects, therapy should be prescribed only by physician familiar with this drug (ie, dermatologist).

A US Food and Drug Administration–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy.

Class Summary

Pimecrolimus cream controls atopic dermatitis.

Pimecrolimus (Elidel)

First nonsteroid cream approved in the United States for mild-to-moderate atopic dermatitis. Derived from ascomycin, a natural substance produced by fungus Streptomyces hygroscopicus var ascomyceticus. Selectively inhibits production and release of inflammatory cytokines from activated T-cells by binding to cytosolic immunophilin receptor macrophilin-12. Resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release. Cutaneous atrophy not observed in clinical trials, a potential advantage over topical corticosteroids. Indicated only after other treatment options have failed.