Rash Around Mouth (Perioral Dermatitis)

What is perioral dermatitis?

Perioral literally means “around the mouth”. Therefore perioral dermatitis refers to skin inflammation (dermatitis) and rashes around the mouth. These rashes can vary in appearance and may be mistaken for other skin conditions of the face like rosacea. Unlike rosacea, the rashes in perioral dermatitis are mainly restricted to the lower half of the face (especially the skin around the mouth), the cheeks and forehead. Perioral dermatitis is a relatively common skin condition and in the United States, 1 out of every 100 people are affected by this rash.

Young women between the ages of 20 and 45 years are the most frequently affected and account for about 90% of all the cases. Children of any age may also developthis rash. Perioral dermatitis is rarely seen in men. People who have this condition are often long term users of corticosteroids (inhaled or topical). It is not a life-threatening condition. However, this does not make it any less debilitating for the sufferers, due to psychosocial impact associated with facial rashes. Often it may be a chronic condition further exacerbating the impact.

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Signs and Symptoms

The most characteristic feature of perioral dermatitis is the presence of a reddish rash that encircles the skin around the mouth. This rash is in the form of red papules (raised bumps). If this rash is present elsewhere on the lips then it needs to be investigated further  The intensity and extent of the rash differs on an individual basis. In some people, it might be light red in color, whereas in others it might be intensely reddish.

The rash may either affect only one side of the skin around the mouth (unilateral) or it may completely encircle the skin around the mouth like a ring (bilateral). A small border around the lips may remain unaffected, and look pale. The papules may also be filled with fluid or pus. Although the term “perioral” suggests that only the skin around the mouth is affected, the rash may also affect some other regions such as the skin on the sides of the eyelids and the nasolabial folds. It has even been reported to affect the vulva region in some young girls.

A burning or stinging sensation may be felt in the skin around the mouth. However, itching is not a common feature of this condition. Perioral dermatitis is limited to the skin. Other tissues are not affected. The skin also becomes dry and flaky.  The rash in perioral dermatitis tends to persist for a long time (months or years). Therefore, it is a chronic condition in most cases.

Causes of Rash Around the Mouth

The exact cause of perioral dermatitis remains unknown. However, a few factors have been implicated based on clinical observations:

  • Cases of perioral dermatitis are most frequently associated with some use of topical steroids on the face. This has led to the suspicion that perioral dermatitis may be caused by long-term treatments of minor skin ailments with corticosteroid-containing creams. Abuse of skin lightening creams containing steroids may also contribute to the development of this condition. It is important to note that the use of topical steroidal creams does not precede every case of perioral dermatitis, suggesting that there are other reasons for the condition.
  • Perioral dermatitis has also been associated with the use of nasal steroids or inhalers containing steroids.
  • Cosmetics applied to the face have also been implicated as a cause for perioral dermatitis. Combined application of moisturizers, foundations and night creams have been shown to be associated with a drastically increased risk of perioral dermatitis. Similarly, skin care creams (especially those containing paraffin base and isopropyl myristate) and sunscreen combinations have also been suspected to result in this skin condition.
  • Use of fluorinated toothpastes have also been associated with perioral dermatitis.
  • Exposure of ultraviolet light, heat and wind may worsen perioral dermatitis.
  • Bacteria and fungi are also thought to contribute to perioral dermatitis, since they have been extracted and cultured from these lesions.
  • Symptoms of perioral dermatitis seem to worsens before menstruation. This has led some to suspect that hormonal factors and use of oral contraceptives may contribute to the development of perioral dermatitis.

Sometimes the rash around the mouth is due to skin conditions like contact dermatitis. This may either be due to skin irritation or an allergic reaction. For example, saliva that remains on the skin for long periods of time can irritate the skin and result in contact dermatitis.

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Treatment for Perioral Dermatitis

Perioral dermatitis

Since the exact cause of perioral dermatitis is not known and may differ between individuals, the treatment is based on the patient history and clinical examination. Laboratory tests are generally not required. The treatment for perioral dermatitis can be broadly classified into topical and oral medication. It is important for patients to know that treatment and remission of perioral dermatitis takes many weeks. Also, the treatment may initially worsen the symptoms before gradually clearing up the dermatitis in some cases.

  • Topical medication: Topical medications are creams or lotions that are applied to the affected areas of the skin. The topical medications that may be prescribed by your dermatologist for treatment of perioral dermatitis include benzoyl peroxide, metronidazole, erythromycin, tacrolimus, clindamycin, sodium sulfacetamide and pimecrolimus. Isotretinoin may be prescribed when all other measures to treat the condition fail.
  • Oral medication: In case of severe dermatitis with a suspected microbial cause, oral antibiotics may be prescribed. These include tetracycline, doxycycline, minoclycine and erythromycin.

Other than the prescribed medications, patients are also advised to take some general measures to help the healing process. Use of all cosmetics (such as face creams, sunscreens, makeup, harsh soaps) should be totally avoided. A rebound flare may happen if a person has been using a potent steroidal cream on the face and stops using it suddenly. Therefore steroid use may be gradually reduced over a period of time. Discontinuing fluoridated toothpaste may be advisable. Strenuous physical activity in hot weather should also be avoided to prevent aggravating the condition. Picking or scratching the affected skin areas should not be done since it may lead to secondary infections.

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