PERIORAL DERMATITIS -------------------------------------------------------- How is your success with perioral dermatitis? Mine has not been so good lately. I have several young-middle aged females with papules, scale, erythema, and small nodules of the perioral and central face. No comedones, rare pustules. Some have features of seb derm, rosacea, acne, contact derm... some have been treated by their GPs with mid-high potency topical steroids prior to seeing me but even after months of being steroid free their eruption persists. I usually treat them with oral antibiotics, erythromycin or minocycline, perhaps benzamycin gel, perhaps low potency topical steroid taper and have them avoid ultra white brightener toothpastes (use Pepsodent). Sometimes I patch test using T.R.U.E. test. Jeffrey N. Thompson,D.O. ------------------------ Maybe telling the patients that after stopping to put potent steroids on it, the eruptions tend to worsen for a while, so that they are not too shocked. I alway tell them there's no other way and that they'll have to be strong for the next days. And, of course, they should stop using their regular cosmetic products to avoid any irritant co-factor. Nothing else than pure water is allowed. Hope I'm not too cruel. If I knew what ABX was, I could comment on this. So PLEASE take your time to write down the generic name in plain text ONCE. Thank you. Remember, the English language won by only one vote... And T.R.U.E. is also beyond my fantasy, what we test here are ointment compounds / local ophthalmologic drugs and the personal cosmetic products as patch test when it looks like an eczema resp. dermatitis. Anyway, this is a disease with lots of trouble for both patient and doc. Hans J. Kammler --------------- Perioral dermatitis is very rare in men (unless they use their wife's moisturizer). Does this say something about the etiology? Haines ELy ---------- I use Doxy, not Minocin (unless doxy doesn't work after one month). If people are using strong steroids, to be kind (!) I give them a desonide lotion sample and wean them. I am suspicious that Dr. Thompsons perioral dermatitis may be a Rosacea variant, with the described nodules. Of course others might be looking for demodex etc. Diane Thaler ------------ Years ago, dermatologist Orville Stone discovered that topical fluoride was "pro-inflammatory" and every since a standard part of therapy for perioral dermatitis by his disciples has been to use non-fluoride toothpaste (eg. non-fluoride Sensidyne). Philip Hughes, M.D. ------------------- Agree with usual approach but I find the benzoyl peroxides are often too irritating for these patients. I addition to Metrocream, I'm having great success with the older approach of Sulfacet or Novacet lotion in addition to the oral antibiotics. Robert M. Peppercorn, M.D. -------------------------- Re perioral dermatitis. I get uniformly good results with topical erythromycin solution. I tell the patients to be d . It can take up to 2 months for full results, but may start working in 1-3 weeks. If erythro fails, tetracycline orally is my backup. Bill Liss --------- For perioral dermatitis, which did not occur and which had never been reported before the advent of fluoridation -- toothpastes, fluorides treatments, and fluorinated cortisocteroids -- I always recommend a non-fluoridated toothpaste. Up until now we were given toothpaste "choices." Now the only one commercially available is the Sensodyne without fluorides. Why do women develop perioral dermatitis more than men? Because their facial skin is much thinner than that of men; their collagen and elastic fibers are packed more loosely and arranged differently; and broken down more readily by external influences like the sun. Also, men have more androgens which is responsible for increased thickenss, the elasticity and resiliency and shininess of the skin. The trade- off, of course, is that men get bald and women get wrinkles! For those with perioral dermatitis, I also explain that they must be patient. Often, however, they are not. They then see another physician (FP) who again prescribes another strong fluorinated steroid preparation. Oral antibiotics, milk compresses, and plain old zinc oxide ointment will cure them after many weeks (or months). Also, no fluoride treatments in the dental chair. Has anyone ever done patch-testing with fluorides?? Jerry Litt ---------- Jerry, I have always thought it was periorificial, that is around the mouth, nose, or eyes-or actually even genital orifices when the medium strength steroids are applied. So-how does the toothpaste get to those other areas? Diane Thaler ------------- It's the perioral, not periorbital, areas that are involved. Wasn't there a recent study showing that tartar-control toothpastes cause perioral eruptions? And almost exclusively in women! People who brush their teeth with their right hand will invariably develop more perioral dermatitis on the left side of the mouth. Jerry Litt ---------- After the moisturizer theory of perioral dermatitis appeared in print several years ago (from someone in Germany) I asked the next ten p.o.d. patients what moisturizer they used. Half of them never used moisturizers at all! Then a patient told me she had traced her recurrent p.o.d. to her use of Carmex on her lips. So, of course, I asked the next ten patients about Carmex, and none of them had even heard of it......I think we need to keep searching for the explanation for this one. Mark Valentine -------------- I can no longer suppress a response to the perioral dermatitis discussion: I have slowly come to think of this as a reaction of the follicle and its perifollicular skin to a variety of agents including fluoride, some topical corticosteroids (strength rather than fluorination seems to be the principal; I have had a patient get it from Westcort), some moisturizers, some simple irritants such as insulation and surgical masks. some sunscreens, etc. As in so many arenas in human biology the final common pathway may look the same but the cause may vary quite a bit. By the way I also have seen this reaction around the nose and the eyes as has been pointed out earlier. For treatment I prefer low dose tetracycline or either sulfacetamide lotion or clindamycin lotion topically and sometimes a mild topical steroid (Vytone). I also have not had problems with Bactrim or Septra but after reading the list I am going to start getting white counts again (I had stopped a few years ago after never seeing a depressed WBC from the drug). Thanks to the group for bringing me back into line. Pat Condry ---------- I still feel that the jury is out on the etiology of perioral dermatitis. We've all seen the patients where it is associated with moisturizers, topical steroids, etc., but I have several women who had clinically "classic" perioral dermatitis who did not use moisturizers, topical steroids, OR fluorinated toothpastes. An older derm in our area once told me he did see perioral dermatitis in the years before fluorinated toothpastes, but just diagnosed it as a variant of rosacea. John Uhlemann ------------- I get it. I don't use moisturizers or anything else. And I can't remember getting toothpaste in the nl crease! Do some flouride proponants feel that it could be an id to the flouride in our water? We should then check out the myriad of well water users-atleast in Wisconsin there a quite a few. Down deep I feel the flouride thing is a leftover for blaming patients, especially women (there I go again) for their diseases which we don't understand. Kind of like dysmenorrhea (sp) being rejection of the uterus and femininity. Which just gave me another etiological idea......but with this one half the blame goes to their consort! Diane Thaler ------------ About fluoride and peri-oral derm: about 10 years ago at the aad show and tell (5 min per case) one presenter said that he had cleared over 60% of his female patients with peri-oral derm just by stopping their fluoride and indeed almost all of my patients with peri-oral derm have used fluoride tooth paste at least bid (no i haven't surveyed my other female patients re:usage but I suspect that like almost all disease you have to be primed genetically to get it) Steve Emmet ----------- Steve, have you had the same experience as the presenter? It seems to me that most people use flouride toothpaste, so the fact that the perioral derm patients do is to be expected. Also, 60% of perioral dermatitis goes away in time when one does nothing except stop moisturizers or aftershave (!), so maybe it wasn't the flouride? Just a thought, Diane Thaler ------------ Being ever the iconoclast, I too wish to voice my scepticism re flourides*, cold-cream, the Ol' man's after-shave etc, as a cause of Perioral dermatitis. After 30 years @ this game, I can only conclude that 1) it's virtually always seen in women only, unless one includes the small naso-labial fold stuff seen occasionally in prepubescent kids (might be a boy from time to time). 2) that it's vaguely classifiable as a subset of rosacea 3) that all topical steroids except 1% HC can mimic it after prolonged use 4) that tetracycline is the only therapy that works predictably (as in rosacea, it is specific). *years ago saw an 8 year old cerebral palsy pt with a florid erythematous, micro-papulo-pustular chin rash that appeared rather convincingly to be from incessant chewing of flouride gum that "he liked". Now Billy did indeed drool, but these other young women? Nah. Mike Eichwald ------------- I agree. One treatment pearl for perioral dermatitis (which I've had great success with) is qhs use of Sulphacet R lotion. Kip Cullimore ------------- What do you think about nitro-imidazol [metronidazole] (topical and systemic) ? Jorge Rozeira M.D. ------------------ It's getting more and more confusing... Since we Europeans like to think in a simple way, we (in our clinic) a) call a rosacea a rosacea (more women than men, over 30 etc.) b) say *rosacea-like dermatitis* when the papules and/or pustules in the face might be a result of external steroid medication or some other agent and the diagnosis *rosacea* just wouldn't convince and c) think that the classical perioral dermatitis is most of the time caused by steroid abuse and nothing else than a rosacea like dermatitis of a certain localization. Hans J. Kammler --------------- If I'm not mistaken, neither Elocon (mometasone) nor Westcort (hydrocortisone valerate) is fluorinated. Mometasone is chlorinated; Westcort is not halogenated at all. The point is that halogenation doesn't mean anything. It is a smokescreen and a historical relic. About fifty years ago, when they tried to make stronger cortisones, they found that fluorination yielded greater potency. They also found fluorination yielded greater side effects. Thus, for a time, fluorination became associated with side effects. Further developments in modification of corticosteroid structure yielded potent corticosteroids without the need for fluorination (examples include mometasone and hydrocortisone valerate). This was a valuable marketing tool becuase physicians would (and I believe still do) prescribe these topical steroids thinking they are getting greater potency without the increased side effect profile of "fluorinated" steroids. Unfortunately, side effects are not due to the fluorination, they are due to the potency of the corticosteroid! It doesn't matter whether there is halogenation or not. Low potency topical steroids have low side effect profiles, and higher potency topical steroids have higher side effect profiles. So far, you can't turn on the corticosteroid receptor to achieve beneficial effects without turning on the side effects induced by the activated receptors. Steve Feldman, MD, PhD ---------------------- This may be the right road in Germany but not in the Pacific Northwest. By far the majority of my perioral dermatitis patients deny ever applying any topical steroids to their face, and I have no reason to believe they are lying to me. Mark Valentine -------------- 1. I don't know the cause but after years of telling people to stop fluoride toothpaste and never having an improvement from this alone I am hard pressed to believe that fluoride is the cause. 2. Wonder about scrubbing and rubbing as an aggravating cause. Whenever I tell patients not to do this, they look at me with this slightly guilty look. 3. Am convinced that once it appears it is "worked over"--patients get quite frantic about it. One Mom told me that her teenage daughter said, when she saw her Mom's case, "Mom, you are *not* going to work with that, are you?" 4. Agree that tetracycline, short course of 6 weeks in tapering dose helps the most. Topicals may help, often aggravate. 5. Other supposed causes are sunlight (possibly an aggravating factor, never itself a cause) and (God forbid!) computer terminal overexposure (don't believe it for a minute!!) Barbara R. Reed --------------- My experience is: Topical steroids are a common cause for perioral dermatitis. Patients using topical steroids often don't know what they use, so let them show you all the ointments they use. Another factor is the use of many cosmetics, parfumed soaps, creams and especially greasy ointments. I tell my patients not to use any cosmetics and to wash only with water. Most patients would not accept using no cream at al, so I give them metronidazol 1% or sometimes erythromycin 1% in a thin o/w emulsion without fragrance and preservation to use once to twice a day. Doxycyclin is quite helpful, but many patients will do without oral antibiotics and their gastrointestinal disorders. I use them only in severe cases or if there is no improvement with local therapy. Sunlight and fresh air in suberythemal doses often help, only sunburn is a sure cause of aggravation. Andreas Eisenmann -----------------