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Persistent red rash near mouth of 6-year-old female
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A 6-year-old female presents to your clinic. Her mother is concerned about a persistent red rash around her mouth for the past 3 to 4 months. She recalls the eruption initially began in the nasolabial folds with a few red bumps and mild scaling that was thought to be eczema.
The patient’s mother applied hydrocortisone 2.5% ointment, which she previously used on her son, for several days with improvement. However, whenever she attempted to discontinue the hydrocortisone, the bumps would quickly recur.
Marissa J. Perman
Can you spot the rash?
Diagnosis: Perioral dermatitis
Perioral, or periorificial, dermatitis is a common inflammatory skin condition seen in children, usually female, on the face. It is often localized to the perioral region but also may involve the nasolabial folds and periocular region. It may be confused with other inflammatory condition of the eyelids, such as chalazion. The etiology of periorificial dermatitis is unknown but may be related to potential irritant exposure.
The location of the lesions in periorificial dermatitis provides clues to the diagnosis. The eruption often begins around the mouth but spares the vermillion border and the skin just beyond the lips, extending to the chin and medial cheeks, as well as the nasolabial folds. Periocular involvement may be absent or minimal in some patients, whereas in other patients it may be the presenting sign. The lesions are usually a combination of erythematous papules, papulopustules and fine scale. The scale, seen less commonly in acne rosacea, often leads to the misdiagnosis of eczema. Patients complain of pruritus and/or burning sensation.
The inciting factor is often difficult to elicit in many patients. However, due to the confusion with eczema, topical steroids are commonly prescribed as an initial treatment. Although topical steroids will help the inflammatory component and improve the appearance of perioral dermatitis, it is difficult to wean off the topical steroids without flaring leading to increasing potencies used with time. This leads to a vicious cycle of improvement followed by flares and, ultimately, steroid addiction, with significant risk of side effects such as atrophy and telangiectasia on the face.
Numerous monomorphic erythematous papules and papulopustules around the mouth, chin, nose and lower eyelids.
Image courtesy of: Perman MJ
Other types of steroids have been implicated in exacerbating perioral dermatitis, including inhaled oral and nasal corticosteroids for asthma and allergic rhinitis. An irritant component is also believed to play a role in development of perioral dermatitis, including various moisturizers and other topical products applied to the face, which may explain the female predominance in this condition.
The differential diagnosis includes acne vulgaris, acne rosacea, lip licker dermatitis (which involves the skin just beyond the lips, as opposed to perioral dermatitis), seborrheic dermatitis, contact dermatitis, sarcoidosis, and inflammatory disorders of the eyelids, such as chalazion.
Several treatment strategies exist, and often practitioners begin with complete avoidance of topical steroids when possible. Families must be counseled on the likelihood of a flare with abrupt discontinuation of steroids, but with improvement over time. Other options include a step-down ladder of topical steroids by strength until the patient can be weaned off without flaring. In the case of inhaled corticosteroids, discontinuation is often not possible. Other alternatives to discontinuation of the offending agent include topical calcineurin inhibitors and topical antibiotics, such as erythromycin and metronidazole. Occasionally, oral antibiotics similar to those used in acne vulgaris, such as erythromycin in younger children and tetracyclines in older children, may be used for several weeks. Rarely, isotretinoin is required for several months.
Avoidance of potentially irritating substances such as scented products and heavy moisturizers may help.
Physicians should be aware of this common but often difficult to treat inflammatory condition in children and adolescents and avoid prescribing topical steroids that may lead to prolonged disease course and significant frustration over time.
References:
- Lipozencic J. Clin Dermatol. 2011;29:157-161.
- Wollenberg A. J Dtsch Dermatol Ges. 2011;9:422427
For more information:
Marissa J. Perman, MD, is an attending physician at The Children’s Hospital of Philadelphia. She can be reached at permanm@email.chop.edu.
Disclosure: Perman reports no relevant financial disclosures.