Medication Summary
In mild cases, as well as in most children and pregnant women, individualized topical therapy is generally recommended. Antimicrobial agents (eg, metronidazole [7, 18, 19, 20] and erythromycin) are administered in a nongreasy base (eg, gel, lotion, cream). Pimecrolimus cream significantly reduced the Perioral Dermatitis Severity Index [21] (PODSI) compared with vehicle in a randomized, double-blind study in adults. [22] Pimecrolimus cream seems to be most effective in steroid-induced perioral dermatitis. [23] A retrospective medical record review from 2020 reported that topical calcineurin inhibitors are effective and well tolerated for treating periorificial dermatitis in pediatric patients. [24] Topical antiacne medications such as adapalene [25] and azelaic acid [26, 27] have been used in open studies. Ointments should be avoided.
In severe forms of perioral dermatitis, systemic treatment with antirosacea drugs is required. The drugs of choice are doxycycline (or tetracycline) and minocycline. In unresponsive and granulomatous forms, oral isotretinoin [28] may be considered. Oral erythromycin can be used in pediatric patients with more severe or refractory involvement.
Zero-therapy is based on the idea that by ceasing use of 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. [29, 30]
In every case, an initial worsening of the symptoms may occur with treatment, especially if topical steroids are withdrawn.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 use of topical steroids, steroid weaning with low-dose 0.1-0.5% hydrocortisone cream can be tried initially.
The use of potent topical steroids is strictly contraindicated. However, in some cases, the initial tapering use of a low-potency corticosteroid (eg, hydrocortisone cream) may be appropriate.
Antibiotics, Other
Class Summary
These drugs may have antibacterial and/or anti-inflammatory effects that are responsible for their effectiveness in perioral dermatitis.
Doxycycline (Oracea, Doryx, Vibramycin)
Doxycycline is the drug of choice in nonpregnant women. It inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Alternatively, one may use tetracycline in adapted dose.
Minocycline (Dynacin, Minocin, Solodyn)
Minocycline is believed to be the most efficacious tetracycline in dermatoses of sebaceous glands. It is 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
Tetracycline inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunits. It has anti-inflammatory activity.
Metronidazole (Flagyl)
Metronidazole is an imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. In concentrations of 0.75-2%, it is considered to be the drug of choice for topical treatment of perioral dermatitis. Metronidazole is available in a gel, lotion, or cream.
Erythromycin (E.E.S., Erythrocin, Ery-Tab)
Topical erythromycin in concentrations of 2-4% as a gel or cream is an alternative to metronidazole for topical treatment. It inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. It is used to treat staphylococcal and streptococcal infections.
Retinoid-Like Agents
Class Summary
These agents reduce the size of the sebaceous glands, decrease sebum secretion, and inhibit keratinization.
Isotretinoin (Amnesteem, Claravis, Sotret)
Isotretinoin is an oral agent used to treat serious dermatologic conditions. It is a synthetic 13-cis isomer of naturally occurring tretinoin (trans -retinoic acid). Both agents are structurally related to vitamin A. Isotretinoin decreases sebaceous gland size and sebum production. It may inhibit sebaceous gland differentiation and abnormal keratinization. Isotretinoin is indicated for long-standing and refractory forms of perioral dermatitis. Because of adverse effects, therapy should be prescribed only by a 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.
Immunomodulators
Class Summary
Pimecrolimus cream controls atopic dermatitis.
Pimecrolimus (Elidel)
Pimecrolimus is the first nonsteroid cream approved in the United States for mild-to-moderate atopic dermatitis. It is derived from ascomycin, a natural substance produced by the fungus Streptomyces hygroscopicus var ascomyceticus. Pimecrolimus selectively inhibits the production and release of inflammatory cytokines from activated T-cells by binding to cytosolic immunophilin receptor macrophilin-12. The resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release. Cutaneous atrophy is not observed in clinical trials, a potential advantage over topical corticosteroids.
-
Perioral dermatitis. Courtesy of Professor Raimo Suhonen and DermNet New Zealand (http://www.dermnetnz.org/assets/Uploads/acne/s/pod6.jpg).
