Mixed diagnoses – 10 cases (2 of 11)

Perioral dermatitis, more accurately also known as periorificial dermatitis

Perioral dermatitis is a common transient, recurrent or persistent rash affecting the muzzle area, hence its name. However, like seborrhoeic dermatitis, it often also affects skin adjacent to the eyes or nose. It appears more common in those with fair-skin and is particularly prevalent in women in their 20's and 30's. It is nearly always provoked or aggravated by face creams, especially topical steroids.
Periorificial dermatitis is characterised by clusters of small papules and surrounding erythema.. The skin surface may be scaly, and occasionally vesicles or tiny pustules develop. Typically, 5-10mm skin adjacent to the vermilion of the lips is unaffected and may appear as a white ring. Symptoms vary from none to itch and burning discomfort depending on the severity and extent of the eruption.

The diagnosis of facial rashes is nearly always made clinically. Occasionally swabs (negative) or skin scrapings are taken. The latter is usually negative, but sometimes malassezia yeasts are found.

Tell your patients to cleanse the face twice daily with mild soap or non-soap non-cream cleanser and water. Emollients are not helpful and may aggravate perioral dermatitis. Patients often demand them however to relieve dryness and stinging; recommend they choose non-oily products including sunscreens.
Oral anti-inflammatory antibiotics such as tetracycline 250-500 mg, doxycycline 100mg daily or minocycline 100mg daily for 4-12 weeks are very reliable. Use erythromycin in pregnancy, if treatment is essential. A longer course may be required for longstanding cases with persistent erythema, and it may need to be repeated for flare-ups.
Topical agents are not very effective for perioral dermatitis and in general are best avoided. Erythromycin, metronidazole or azelaic acid preparations may be helpful if oral treatment is contraindicated. If a topical steroid has been used, warn of a possible flare-up on stopping and if necessary continue a milder product at decreasing intervals over two or three weeks.