eMedicine Specialties > Dermatology > Diseases of the Adnexa
Perioral Dermatitis: Treatment & Medication
Updated: Oct 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- Anti-inflammatory systemic and/or topical therapy is required. Photodynamic therapy (PDT) has been reported to be helpful for perioral dermatitis (POD),10 although large studies have not yet been performed.
- Treatment should be adapted to the severity and extension of the disease.
- Reassurance and education about possible underlying factors and the time course of the disease are critical. These measures help the patient to cope with the disfiguring character of the disease and help to minimize the risk of recurrences.
Consultations
Consult a dermatologist to evaluate provoking factors and to determine the individualized treatment.
Diet
As with all inflammatory skin conditions and rosacea, substances that dilate dermal blood vessels should be avoided. Examples include alcohol and hot foods.
Activity
In general, physical activity is not restricted; however, vasodilation of dermal vessels due to strenuous physical exercise may worsen subjective symptoms.
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 isotretinoin11 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, metronidazole12,13,14,5 and erythromycin) are administered in a nongreasy base (eg, gel, lotion, cream). Pimecrolimus cream significantly reduced the novel Perioral Dermatitis Severity Index15 (PODSI) compared with vehicle in a randomized, double-blind study.16 Pimecrolimus cream seems to be most effective in steroid-induced perioral dermatitis.17 Topical antiacne medications such as adapalene18 and azelaic acid19,20 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. So-called zero-therapy may be effective in cases associated with steroid abuse or when intolerance to cosmetics is suspected.21 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.
Systemic antibiotics
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.
Adult
100 mg PO bid initially; reduce to 50 mg bid or 100 mg qd after significant clinical improvement
Pediatric
<8 years: Not recommended
>8 years: 0.5 mg/kg PO bid; not to exceed 100 mg bid
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increasing risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconi-like syndrome may occur with outdated tetracyclines; overgrowth of nonsusceptible organisms, including fungi, may occur; discontinue use if superinfection occurs; pseudotumor cerebri (benign intracranial hypertension) associated with tetracycline use in adults (usual clinical manifestations are headache and blurred vision); bulging fontanels associated with use of tetracycline use in infants; although conditions and related symptoms usually resolve soon after discontinuation, permanent sequelae possible
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.
Adult
50-100 mg PO bid initially; reduce frequency to qd after notable clinical improvement
Pediatric
<8 years: Not recommended
>8 years: 1 mg/kg PO bid; not to exceed 100 mg PO bid
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Associated with drug-induced lupus syndrome and hepatitis; overgrowth of nonsusceptible organisms, including fungi, may occur; discontinue use if superinfection occurs; pseudotumor cerebri (benign intracranial hypertension) in adults associated with tetracycline use (usual clinical manifestations are headache and blurred vision); bulging fontanels associated with use of tetracyclines in infants; although conditions and related symptoms usually resolve soon after discontinuation, sequelae possible; photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconi-like syndrome may occur with outdated tetracyclines; hepatitis or lupuslike syndromes may occur.
Tetracycline (Sumycin)
Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunits. Has anti-inflammatory activity.
Adult
500 mg PO tid during wk 1; 500 mg PO bid during wk 2; 250-500 mg PO qd for as long as 6 wk
Pediatric
<8 years: Not recommended
>8 years: 10 mg/kg PO tid initially; not to exceed 500 mg PO tid
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconi-like syndrome may occur with outdated tetracyclines
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.
Adult
Topical: Apply to affected areas bid after washing
Oral: 250-500 mg PO bid
Pediatric
Not established
Cimetidine may increase toxicity; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with oral ingestion of alcohol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Topical metronidazole may cause tearing of eyes; contact with eyes should be avoided; if reaction suggesting local irritation occurs, use medication less frequently or discontinue; drug is a nitroimidazole and should be used with care in patients with evidence of or history of blood dyscrasia; alcoholic beverages should be avoided during and for at least 3 d afterward oral treatment; PO metronidazole should not be given to patients who have taken disulfiram within previous 2 wk
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.
Adult
Apply to affected areas bid after washing
Pediatric
Apply as in adults
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid contact with eyes and all mucous membranes; antibiotic agents may be associated with overgrowth of antibiotic-resistant organisms; discontinue use if superinfection occurs
Retinoids
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.
Adult
0.2 mg/kg PO qd initially; reduce to 0.1 mg/kg or 0.05 mg/kg upon notable clinical improvement
Pediatric
Not established
Toxicity may occur with vitamin A coadministration; pseudotumor cerebri or papilledema may occur when coadministered with tetracyclines; avoid alcohol consumption (possible potentiation of increase in serum triglyceride levels); may reduce plasma levels of carbamazepine
Documented hypersensitivity
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Women of childbearing age must not become pregnant during therapy; decreased tolerance to contact lenses may occur during and after therapy; may decrease night vision; patients should not donate blood during therapy and for 1 mo afterward; female patients should use 2 forms of effective contraception during and for 1 mo after treatment; patients should sign a consent form prior to therapy; use during breastfeeding and in children not recommended; inflammatory bowel disease may occur; may be associated with hepatitis; occasional exaggerated healing response of acne lesions (excessive granulation with crusting) may occur; patients with diabetes may have problems in controlling their blood sugar during treatment; patient should avoid exposure to UV light or sunlight until tolerance achieved; discontinue treatment if rectal bleeding, abdominal pain, or severe diarrhea occur; mood swings or depression may occur; caution with history of depression.
Immune modulators
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.
Adult
Apply topically to affected areas bid (short-term and intermittent use only)
Pediatric
<2 years: Not established
>2 years: Administer as in adults (short-term and intermittent use only)
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Potential exacerbation of existing infection at site of application; may cause burning and irritation; caution with conditions that suppress the immune system (eg, AIDS, cancer); may increase risk of viral infections; other adverse effects include headache, sore throat, flulike symptoms, fever, and cough
More on Perioral Dermatitis |
| Overview: Perioral Dermatitis |
| Differential Diagnoses & Workup: Perioral Dermatitis |
 Treatment & Medication: Perioral Dermatitis |
| Follow-up: Perioral Dermatitis |
| References |
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References
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Further Reading
Keywords
perioral dermatitis, POD, rosacealike dermatitis, periorificial dermatitis, light-sensitive seborrheid, chronic papulopustular facial dermatitis, papulopustular facial dermatitis, granulomatous perioral dermatitis, lupuslike perioral dermatitis
