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What is Perioral dermatitis?

Perioral dermatitis is a type of dermatitis that occurs only around the mouth, nose and eyes. It does not have to be present in all of the areas at the same time.

Some dermatologists believe that Perioral dermatitis does really exist and that patients that fit the clinical picture of Perioral dermatitis has Rosacea. Rosacea and Perioral dermatitis can sometimes be present in the same patient. Because it is always more likely that a patient has 1 condition rather than two, the finding of both Rosacea and Perioral dermatitis in the same patient support to the thesis that the 2 conditions are in fact the same. Furthermore, when looking at a sample of skin under the microscope, both Rosacea and Perioral dermatitis displays the same type of inflammation, knows as a granulomatous peri-folliculitis. The word granulomatous refers to a collection of macrophages (a type of white blood cell). Peri-folliculitis means that the “collection of macrophages” is lying in close proximity to a hair follicle.

Whether or not Rosacea and Perioral dermatitis are the same disease or two separate diseases is an academic question and not very important from a treatment perspective. The fact is that the clinical picture known as Perioral dermatitis is quite classic and most often easily recognizable and treatable.

Classically young female patients are affected. The rash consists of small red bumps (knows as papules) and occasionally small pimples (knows a pustules) occurring around the mouth, nose and eyes. Interestingly, a small margin of skin around the edge of the lips are always unaffected. As mentioned before not all 3 of these areas has to be affected at the same time.

More than 80% of patients with Perioral dermatitis have been applying corticosteroid-containing creams to the face, before the rash started to appear. In the remaining cases the cause is unclear, but the excessive use of facial products seem to be another common factor.

The treatment of this condition involves the elimination of all (if possible) facial products. If topical corticosteroid-containing creams have been used they should be tapered off slowly and not stopped suddenly, because this will lead to a flare-up of the condition.

The treatment of Perioral dermatitis involves the use of oral tetracycline antibiotics for a few months. Sometimes this is combined with antibiotic creams, but in general it is better to avoid as many creams as possible. Most often this approach results in complete clearance of the skin condition in a few weeks.

Perioral dermatitis treatment

Perioral dermatitis is sometimes also called Perioral-nasal-ocular dermatitis (PONOD) or periorificial dermatitis, because the rash can also appear around the nose and eyes.

Perioral dermatitis is associated with the use of facial products. Most patients with Perioral dermatitis are using multiple different types of facial products. The use of corticosteroid containing creams over extended periods are strongly linked to the development of Perioral dermatitis. One of the most important aspects of the treatment of Perioral dermatitis is therefore the gradual elimination of all non-essential facial products.

Depending on the severity of the Perioral dermatitis the above process is started while taking an oral Tetracycline antibiotic, like Minocycline, Doxycycline or Lymecycline. Normally this antibiotic must be continued for at least 3 months (or until the rash has disappeared) and is then tapered off over a 2 month period.

Paradoxically, the early phases of the treatment of Perioral dermatitis might involve using a mild topical corticosteroid cream on the face to calm down the active redness and inflammation. The most commonly used corticosteroid cream contains Mometasone furoate. This is initially applied daily until the redness subsides and then tapered off as soon as possible.

The tapering off process of the corticosteroid cream normally occurs over a few weeks. The average patient will use the corticosteroid cream daily for about 5 days, on alternate days for about 4 days, twice a week for about 2 weeks and after that maybe once or twice a month. There is however considerable variation.

While the corticosteroid cream is tapered off the oral antibiotic is continued until the rash has been absent for at least a month. Only then is the oral antibiotic also tapered off. It is extremely important that during this treatment period all non essential facial products (yes all!) must be gradually eliminated. If this is not entirely possible then try to eliminate as many facial products as you can. Only after all facial products have been stopped and the Perioral dermatitis has been clear for at least one month, can facial products be gradually reintroduced one by one.

Perioral dermatitis is normally quite responsive to the above treatment regime and most patients will experience a marked improvement in only a few days to weeks.

Elidel

ElidelThe active ingredient is Elide, Pimecrolimus, is an immunosuppressant derived from Ascomycin. Ascomycin is produced by the fungus Streptomyces hygroscopicus.

Topical Pimecrolimus become available for prescription around 2001. Pimecrolimus cream comes in one strength (1%) and is available in 30g, 60g and 100g tubes.

The most important use for Pimecrolimus (Elidel) cream is to treat Atopic Dermatitis. The manufacturer recommends that Pimecrolimus (Elidel) should only be used for age 2yr and older, but is has been used successfully in younger children. Pimecrolimus (Elidel) works by inhibiting the molecule Calcineurin that is essential for activating T-lymphocytes. T-lymphocytes, which are white blood cells, play an active role in Atopic Dermatitis. When T-lymphocytes become activated they help to induce a flare-up of Atopic Eczema.

Pimecrolimus (Elidel) is most often used as a third line treatment for Atopic Dermatitis. First line treatment is emollients and second line treatment is topical corticosteroids. Pimecrolimus (Elidel) is often prescribed when it is difficult or impossible for eczema-sufferers to wean themselves of topical corticosteroids. The extra immunosuppressive effect of the Pimecrolimus (Elidel) should allow most patients to reduce the topical corticosteroids needed to control the dermatitis.

A comparison of Pimecrolimus (Elidel) with Tacrolimus 0.03% showed no significant differences in efficacy at 6 weeks after treatment started. Tacrolimus 0.1% is more potent that Pimecrolimus (Elidel) and 0.03% Tacrolimus.

Side effects from using Pimecrolimus (Elidel) cream are mild. About 4% of people using Pimecrolimus (Elidel) will experience a burning or stinging sensation where they apply the Pimecrolimus (Elidel). The burning sensation disappears in about 15 minutes. It only occurs in the first week or two and in active patches of dermatitis.

The long-term risks (years) of using Pimecrolimus (Elidel) is unclear. The biggest concern about Pimecrolimus (Elidel) cream is that it might raise the risk of developing skin cancers. People using Pimecrolimus (Elidel) cream should limit their exposure to sunlight. In animal studies Pimecrolimus (Elidel) speeded up the cancer-forming effects of sunlight. There have been a few people that have developed a skin cancer while using Pimecrolimus (Elidel). Four of these were skin lymphomas.

The skin cancers occurred on average 90 days after the start of therapy. It is unclear if Pimecrolimus (Elidel) caused the skin cancers or whether the skin cancers would have developed anyway. Until long-term data becomes available Pimecrolimus (Elidel) will probably remain an important third line treatment for eczema-sufferers finding it difficult or impossible to wean themselves of topical corticosteroids.

Seborrheic dermatitis

Seborrhoeic_eczemaSeborrheic dermatitis/eczema is a form of eczema that can appear only on certain parts of the body. The appearance of the rash varies depending on the area of the body that is involved. On the scalp the rash typically appears red and scaly, whereas in the skin folds the rash is typically devoid of scale and therefore appears red and moist.

The typical areas of the body that can be involved by Seborrheic dermatitis are as follows:

  • Scalp
  • The skin fold behind the ears
  • The skin fold between the nose and cheeks
  • The ear canals
  • The eyebrows
  • The mid chest
  • The mid back
  • The groin area, including the skin folds between the upper legs and abdomen

Not all of these areas have to be involved and most often it is just the scalp areas.

The rash is generally not very itchy, but some people describe a burning sensation on the involved areas, especially the scalp. People that suffer from so-called “Dandruff” is frequently in fact suffering from Seborrheic dermatitis. Dandruff is not a medical diagnosis and refers to the small white skin flakes occurring on the scalp. There can be many reason for excessive flaking of the scalp, of which Seborrheic dermatitis is one.

Seborrheic dermatitis occurs in two separate age groups, before 1 year of age and after puberty. After puberty men tends to be affected more often than women.

Nobody really knows the cause of Seborrheic dermatitis, but the overgrowth of a certain organism called Pityrosporum ovale has been implicated. However, not all people with Seborrheic dermatitis have Pityrosporum ovale overgrowth. The finding of huge numbers of Pityrosporum ovale in areas of Seborrheic dermatitis might therefore be just the result of the Seborrheic dermatitis and not the cause of the Seborrheic dermatitis. Another theory about the cause of Seborrheic dermatitis is that Seborrheic dermatitis is a disease of skin overgrowth just like Psoriasis.

Another important association with Seborrheic dermatitis is infection with HIV. People with HIV tend to develop Seborrheic dermatitis when the suppression of their immune systems reaches a certain level.

The treatment of Seborrheic dermatitis involves the use of various shampoos containing one or more of the following ingredients: Zinc, Selenium, tar and anti-fungals. A corticosteroid containing lotion, cream or mouse can be used during a flare up. Recently Tacrolimus and Pimecrolimus has also been used successfully for the treatment of Seborrheic dermatitis.

The treatment of Rosacea

The full medical name of Rosacea is Acne Rosacea. Rosacea affects two components of the skin, hair follicles and blood vessels. Especially hair follicles that have large oil glands attached are afffected. These hair follicles are found on the face, chest and back. No one knows exactly what causes Rosacea. One theory suggest that a certain organism, called Demodex, is the cause of the hair follicle problems. Another theory suggests that the blood vessel problem is related to sun damage of the tissue around blood vessels. Middle aged people are the most commonly affected age group. Rosacea goes through different phases of development and the treatment of Rosacea in each phase is different.

Phase 1: Intermittent flushing

The intermittent flushing phase tends to be triggered by sun exposure or other factors like warm drinks, warm food, alcohol or spicy food. The treatment of this phase involves avoiding the trigger factors and applying sunblock.

Phase 2: Persistent redness and broken capillaries

The redness and broken capillaries are best treated with a laser or intense pulsed light device.

Phase 3: Pimples

The pimple phase is treated with topical medication (creams, gels and ointments) or systemic medication (tablets or capsules). Topical medications include Metronidazole gel (Rozex gel) and Azeleic acid (Skinoren). Oral medications include Tetracycline derived antibiotics (Minocycline, Lymecycline, Doxycyline) and Vitamin A derived medication called Isotretinoin (Roaccutane, Oratane, Acnetane). Patients have to take these medications for weeks to months to control the Rosacea.

Phase 4: Permanent swelling of the nose and occasionally other areas

Rosacea can cause permanent enlargement of the oil glands. This enlargment of the oil glands leads to swelling. Swelling of the nose is called Rhinophyma. Rhinophyma can be treated with Vitamin A derived medication called Isotretinoin, surgically, with laser or with a process called Dermabrasion.

In addition to the skin symptoms, Rosacea can also cause red itchy eyes.