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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.

What is Cradle Cap?

Baby With Cradle CapCradle cap is a term used to refer to any red scaly rash on the scalp of babies. Cradle cap is not a medical diagnosis, but simply a descriptive term, like the term diaper dermatitis.

There are a few causes of Cradle cap, including Seborrheic dermatitis, Atopic Dermatitis and Plaque Psoriasis. Seborrheic dermatitis is the most common cause of cradle cap. Before Cradle Cap can be treated, the specific cause of the Cradle cap must first be diagnosed. To diagnose the cause of the Cradle cap your doctor will have to examine the baby from head to toe.

A concomitant rash in the skin-folds and the nappy area might indicate Seborrheic dermatitis, whereas a generally dry skin might indicate Atopic Dermatitis as the cause of the Cradle cap. Nobody knows exactly why babies develop Seborrheic dermatitis or Atopic Dermatitis. The theory is that Seborrheic dermatitis is related to the overgrowth of the yeast Pityrosporum ovale which was recently renamed Malassezia furfur. The yeast overgrows because of overactive oil glands on the scalp. The oil glands become overactive because of genetic influences or perhaps because of hormones passed to the baby from the mother.  Seborrheic dermatitis is not due to bad hygiene or a bad diet! Perhaps as many as 50% of babies born in the developed world have some degree of cradle cap.

Once the diagnosis is made, treatment can be started. The following treatment options will apply especially to Cradle cap caused by Seborrheic dermatitis.

The are really 2 aspects of Cradle cap to treat; scaling and redness. The scaling develops from the areas of redness. Once the redness is resolved the scaling will cease. Initially however, treatment is targeted at both scaling and redness.

Redness can be treated with mild topical corticosteroids. Corticosteroids is not dangerous if used correctly and sparingly. Do not let anybody tell you different, because mild topical corticosteroids can rapidly improve the condition and make your baby feel better. Mild topical corticosteroids should be applied once of twice per day while there is redness. If there is no redness do not apply any corticosteroids.

Ketoconazole containing shampoos can also help. Ketoconazole is an anti-fungal that will help to eradicate yeasts. It is a good idea to dilute the Ketoconazole shampoo perhaps 50:50 or greater initially, to make sure the shampoo does not irritate the babies skin. Use the shampoo every second day initially. Ketoconazole creams can also be applied once or twice per day to the red areas.

Scaling is treated by moisturising the skin. Many different oil and creams can be used for this. Examples include Vaseline, over-the-counter moisturizers, olive oil, borage oil, tea-tree oil, aloe gel etc.

Cradle cap due to Seborrheic dermatitis will resolve spontaneously within a few months in the vast majority of babies.

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.

How to treat nappy rash

The term nappy rash simply refers to a rash in the nappy area. Many conditions can cause a rash in the nappy area. The first step is to determine what the cause of the nappy rash is.

Conditions that can cause a rash in the nappy area:

  • Primary irritant dermatitis
  • Candida infection
  • Atopic dermatitis
  • Allergic Contact Dermatitis
  • Seborrheic dermatitis
  • Psoriasis
  • Acrodermatitis Enteropathica
  • Langerhans Cell Histiocytosis
  • Bullous Mastocytosis
  • Incontinentia pigmenti
  • Bullous Pemfigoid
  • Dermatitis Herpetiformis
  • Linear IgA disease
  • Epidermolysis Bullosa
  • Herpes Simplex virus infection
  • Bullous Impetigo
  • Tinea cruris
  • Scabies
  • Papular urticaria

See why is it essential to determine the cause first?!

The most common cause of nappy dermatitis is Primary irritant dermatitis. Primary irritant dermatitis is a result of urine and faeces irritating the skin. The irritation of the skin is due to wetness, the alkalinity of urine and faeces, irritating enzymes in urine and faeces and secondary infection with Candida and bacteria.

The initiating irritating factor is wetness. The most important part of the treatment of Primary irritant dermatitis is to keep the baby’s bottom DRY. Regular nappy changes, frequently enough to prevent too much wetness, is the most important part of the treatment. Nappy changes can be reduced by using more absorbent nappies. After every nappy change apply a nourishing moisturiser to help repair the skin.

Inflammation (redness) can be treated with mild corticosteroid ointments.

Small sores and ulcers can be covered with Vaseline / White soft paraffin or Zinc oxide ointment.

Infections can be treated with antifungal creams and antibacterial creams.

How to treat dandruff

Dandruff is a non-medical term for a scaly scalp. Many different conditions can cause a scaly scalp. The most common skin condition that causes dandruff is Seborrheic Dermatitis, followed closely by Atopic Dermatitis. Seborrheic Dermatitis tends to flare during  stressful periods.

The first step in treating dandruff is to decide which condition is causing the dandruff.

If the cause is Seborrheic Dermatitis the treatment is as follows:

Step 1:

Shampoos containing ketoconazole, e.g. Nizshampoo.
The shampoo is used 3-4 x per week and left on for a few minutes before rinsing off. Some people need to continue this process for years. If ketoconazole shampoo is not sufficient to control the dandruff the treatment in Step 2 is added.

Step 2:

Scalp lotions containing corticosteroids, e.g. Advantan scalp lotion, Synalar gel and Dermovate scalp lotion.
These lotions are best applied after washing the hair, while the scalp is still moist.

Step 3:

Shampoos containing corticosteroids, e.g. Clobex shampoo. Clobex shampoo is applied on dry hair. The Clobex shampoo can be washed off with the Ketoconazole containing shampoo.

Step 4:

Oral medications containing antifungals, e.g. Nizoral tablets or Sporonox tablets.
Most often, step 1, the ketoconazole containing shampoo, is all that is required

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.