Progressive papulopustular periorificial process

February 23, 2015
fig. 1

Clinical Vignette

An unhappy mother tells you that she is not leaving the office until you make her daughter’s face normal again. The healthy 11-year-old girl has had an asymptomatic slowly progressive eruption which started around her mouth 3 years ago and spread around her nose and eyes over the last year. What’s your diagnosis?

Diagnosis and Clinical Presentation

Diagnosis: Periorificial dermatitis Periorificial Dermatitis(PD) is a common acneiform eruption of unknown origin most commonly found around the mouth although lesions frequently spread around the nose and eyes (1-8). Although PD may develop without antecedent use of topical steroids, it is often triggered by the chronic use of topical steroids for a pre-existing dermatosis, such as a contact dermatitis, and may be persistent for months to years. When periorificial dermatitis is treated with topical steroids, the eruption usually subsides for weeks to months only to rebound when treatment is tapered requiring higher and higher potency topical steroids to control. Clusters of follicular-bases red papules, papulovesicles, and papulopustules develop on a red base and may become confluent around the mouth but typically spare the vermillion border and the immediately surrounding skin. Similar lesions may develop around the nose and on the eye lids. Erythema, scaling, or both were noted in 86% of patients, papules were noted in 66% and pustules in 11% (8). In a recent case series of 79 affected children, isolated perioral involvement was seen in 39% of patients, perinasal (around nose, nostril) alone in 13%, periocular alone in 1%, perioral and perinasal in 14%, perinasal and periocular in 6%, perioral and periocular in 6%, and perioral and perinasal and periocular in 10% (8). Although PD is usually asymptomatic, mild pruritus is reported in 19% of patients and 4% complained of burning or tenderness (8).

Epidemiology and pathogenesis

This primarily facial eruption affects young women most commonly as well as children, and has an incidence of 0.5-1% in industrialized countries, independent of geographic factors.1 Medications in use at the time of diagnosis included topical steroids (66%) and topical antifungals (20%) (8). The clinical and histologic features overlap with those of acne rosacea. The etiology of perioral dermatitis is unknown; however, the chronic use of topical steroids for minor facial dermatoses has been implicated as a causative factor in many patients. Recently, neurogenic inflammation has also been proposed as a pathogenic mechanism. In some patients skin care ointments and creams, especially those with a petrolatum or paraffin base, and the vehicle isopropyl myristate may trigger the eruption.1 Gastrointestinal disturbances, such as malabsorption, may be a predisposing factor. Although Fusiform spirilla bacteria, Candida species, and other fungi have been cultured from lesions, their role in PD is unclear.

Treatment

Patients require topical and/or systemic treatment, evaluation for predisposing factors, and reassurance. Before initiating medical treatment, patients should be advised to discontinue predisposing cosmetic facial creams, sunscreens, and topical steroids. Rebound after discontinuation of steroids may require restarting the topical agents and tapering over 2-3 weeks. Topical antibiotics including metrinidazole, erythromycin, mupirocin, and sulfacetamide have been reported to successfully treat PD (8). However, when these agents fail or the skin is too irritated to tolerate topical therapy, oral antibiotics including erythromycin (30 mg/kg/d divided in 3 doses) in preadolescents and tetracycline derivatives in adolescents (at doses similar to management for acne vulgaris) are usually effective. It is important to emphasize that patients may require 2-3 months of therapy to clear, and they should not anticipate significant improvement for at least 2-4 weeks (7).

Our Patient

Our patient cleared with 8 weeks of oral erythromycin 30 mg/kg/day administered in 3 divided doses.

Conclusion

Periorificial dermatitis should be considered in any child presenting with an asymptomatic chronic papulopustular rosacia-like process developing around the eyes, nose, and mouth.

References

  1. 1. Guarneri F, Marini H. An unusual case of perioral dermatitis: possible pathogenic role of neurogenic inflammation. J Eur Acad Dermatol Venereol. March 2007;21(3):410-2. 2. J.H. Kuflik, C.K. Janniger and Z. Piela, Perioral dermatitis: an acneiform eruption, Cutis 67 (2001), pp. 21–22. 3. K. Boeck, D. Abeck, S. Werfel and J. Ring, Perioral dermatitis in children—clinical presentation, pathogenesis-related factors and response to topical metronidazole, Dermatology 195 (1997), pp. 235–238. 4. S.M. Manders and A.W. Lucky, Perioral dermatitis in childhood, J Am Acad Dermatol 27 (1992), pp. 688–692. 5. I.J. Frieden, N.S. Prose, V. Fletcher and M.L. Turner, Granulomatous perioral dermatitis in children, Arch Dermatol 125 (1989), pp. 369–373. 6. J.C. Dubus, C. Marguet, A. Deschildre, L. Mely, P. Le Roux and J. Brouard et al., Local side-effects of inhaled corticosteroids in asthmatic children: influence of drug, dose, age, and device, Allergy 56 (2001), pp. 944–948. 7. http://dermnetzn.org/acne/perioral dermatitis.html 8. V Nguyen, Eichenfield, L. Periorificial dermatitis in children and adolescents. J Am Acad Dermatol (2006), pp781-785

Pattern

Morphology

Pigmentation

Body Site