Perioral dermatitis

The disorder appears to have made a sudden appearance with a case of 'light sensitive seborrhoeid' in 1957, which is said to be the first nearest description of the condition. By 1964, the condition in adults became popularly known as perioral dermatitis, but without clear clinical criteria. That this condition should be renamed periorificial dermatitis has been proposed. == Signs and symptoms ==

A stinging and burning sensation with rash is often felt and noticed, but itching is less common. These areas of skin are felt to be drier and therefore there is a tendency to moisturize them more frequently. Hence, they do not tolerate drying agents well, and they often worsen the rash. There are no comedones in perioral dermatitis. == Causes ==

The exact cause of perioral dermatitis is unclear; however, some associations are suspected. There have been clinical trials to look at the link between perioral dermatitis and steroids, infections, and typical facial products. These factors may play a role in the development of perioral dermatitis. Corticosteroids Perioral dermatitis can occur with corticosteroids. Corticosteroids are anti-inflammatory medications used to reduce swelling and redness caused by the body. There are different forms of steroids, many of which can contribute to the development of perioral dermatitis. There are different types of the infections such as bacterial, yeast, and parasitic. From different clinical trials, it seems that a bacterial infection is more likely to lead to perioral dermatitis than the other types. Barrier dysfunction is seen as a large cosmetic association to perioral dermatitis. These are potential associations to perioral dermatitis and thoughts of how it may cause perioral dermatitis; however, the exact pathology is still unknown. Perioral dermatitis can also be caused by other factors, such as stress, oily secretions, and fluid intake, all of which were impacted as COVID cases increased, which further increased the rates of wearing masks. This, in turn, resulted in an increased level of stress and oil secretions along the face and decreased intake of water. == Pathophysiology ==

The pathophysiology of perioral dermatitis is related to disease of the hair follicle, as is now included in the ICD-11, due to be finalized in 2018. Lip licker's dermatitis or perioral irritant contact dermatitis due to lip-licking is considered a separate disease categorized under irritant contact dermatitis due to saliva. Perioral dermatitis is frequently histologically similar to rosacea, with the two conditions overlapping considerably. There is a lymphohistiocytic infiltrate with perifollicular localization and marked granulomatous inflammation. Occasionally, perifollicular abscesses may be present when pustules and papules are the dominant clinical findings. == Diagnosis ==

A diagnosis of perioral dermatitis is typically made based on the characteristics of the rash. A skin biopsy is usually not required to make the diagnosis, but can be helpful to rule out other skin diseases that may resemble perioral dermatitis. Extended patch testing may also be useful to rule out allergic contact causes. If the skin biopsy shows signs of other components such as bacteria, the healthcare workers can do further lab testing, such as culture or other tests like a diascopy. Other skin diseases that may resemble perioral dermatitis include: • Rosacea • Acne vulgaris • Seborrheic dermatitis • Allergic contact dermatitis • Irritant contact dermatitis • Angular cheilitis • Sarcoidosis • Lip licker's cheilitis • Demodex folliculitis • Tinea faciei • Syringomas ==Treatment==

Multiple treatment regimes are available, and treatment algorithms have been proposed. Most treatment plans were developed through trial and error. Treatment plans usually consist of a systemic treatment such as an oral antibiotic or a topical treatment like metronidazole. Perioral dermatitis usually resolves within a few months without medication by limiting the use of irritants, including products with fragrance, cosmetics, benzoyl peroxide, occlusive sunscreens, and various acne products. This is called zero treatment. Topical corticosteroids should be stopped entirely if possible. Abrupt discontinuation of a topical corticosteroid may lead to rebound flares that can be worse than the primary dermatitis. If the flare proves intolerable, temporary use of a less potent topical corticosteroid can often be helpful. Medication Several medications, either applied directly to the skin or taken by mouth, may speed recovery. These include tetracycline, doxycycline, and erythromycin. Tetracycline is given at a daily dosage of 250 to 500 mg twice a day for 4 to 8 weeks. Pregnant women and pediatric patients can not take tetracycline due to possible harm to the fetus and severe staining of developing teeth. The most common medications to treat perioral dermatitis are oral tetracycline, pimecrolimus cream, and azelaic gel. However, some of these medications can't be used for prolonged periods, otherwise they will no longer be effective against the disease. For example, the use of pimecrolimus cream for more than four weeks will be ineffective, while the use of azelaic acid gel for more than six weeks will be ineffective. While these two medications previously mentioned decrease in effectiveness after a certain period, oral tetracycline, on the other hand, have been shown to have decreased effectiveness if used prior to twenty days of disease diagnosis. While there may be other topical medications that can be effective against perioral dermatitis, such as erythromycin emulsion or metronidazole cream, studies have shown that their effectiveness varied among different randomized controlled trials. As a result, these two topical medications, amongst others, may not be the ideal solution for perioral dermatitis. For more rare cases, cefcapene pivoxil hydrochloride, a beta-lactam antibiotic, has been used in treating perioral dermatitis presumably caused by Fusobacteria. Improvement was visible in 1 to 2 weeks and cured in 2 to 5 weeks. When giving patients their medication, healthcare workers must be aware of the possibility of the perioral dermatitis returning to the patient again, as well as exacerbation. If the perioral dermatitis comes back again, the medication that they took prior may not work the second time around, so the healthcare workers may need to create a secondary treatment plan around the return of the disease. == Prognosis ==

Perioral dermatitis is likely to fully resolve with short courses of antibiotics, but if left untreated, it can persist for years and take on a chronic form. Improvement with tetracyclines is usually seen after 4 days and significantly so after 2 weeks. In severe cases, longer periods of treatment may be required to achieve cosmetic satisfaction. == Epidemiology ==

Most commonly in females between the ages of 16 and 45 years, perioral dermatitis also occurs equally in all racial and ethnic backgrounds, and includes children as young as three months, and is increasingly reported in males. While perioral dermatitis is more prevalent amongst young females compared to male, the reason behind why is unclear. In adults, women are more likely to be affected than men. The most affected age group is those in their twenties or thirties. However, in children, the most affected populations are those before puberty, and boys are more affected than girls. Amongst the few adult men who find themselves diagnosed with perioral dermatitis, it has been shown in multiple studies that the reason behind it is due to their taking volatile alkyl nitrates, an inhaled product used to relax muscles. == Impacts ==

Many individuals who have perioral dermatitis, amongst other skin issues, have an increased risk of experiencing mental health issues, such as depression, anxiety, and stress. This is particularly more prevalent in adolescents, compared to adults, due to the presence of more social stigmas during one's teen years as opposed to one's adulthood. Individuals who use topical steroids long past standard treatment plans or chronically may increase the risk of developing other severe diseases, such as severe dermatitis. == See also ==