NHS guidance on perioral dermatitis

What does perioral dermatitis look like?

Perioral dermatitis causes clusters of small bumps and dry, flaky patches, usually around the mouth. The rash can also appear around the nose and eyes, when it is sometimes called periorificial dermatitis. Burning, itching or soreness can accompany the rash, but some people have little discomfort. A narrow strip of skin immediately beside the lips often stays unaffected.14

The bumps can look pink, red or purple, or subtly darker than the surrounding skin. In darker skin, bumps can also look flesh coloured, and redness can be harder to see. Some spots contain pus. Colour alone is therefore not enough to identify the condition.12

Is it acne, eczema or rosacea?

Perioral dermatitis can resemble acne or rosacea, but it is a separate condition. Unlike acne, it does not produce comedones, meaning blackheads and whiteheads. A clinician usually diagnoses it by examining the rash, its distribution and your medical history. Contact dermatitis and seborrhoeic dermatitis are other possibilities that need to be considered; a skin biopsy is rarely necessary. Perioral dermatitis is not contagious.145

What can trigger it?

The exact cause is not fully understood. Steroid exposure is an important association, including facial steroid creams, steroid tablets, inhalers and nasal preparations. Thick moisturisers and cosmetics that form a barrier over the skin can also contribute. Hormonal changes, including pregnancy, are possible triggers. The condition occurs across ages and skin types, although it is more common in women.145

Fluoride exposure, including toothpaste, is another possible trigger. This is a possibility to discuss during a review of your routine, not a way to diagnose the rash from the toothpaste tube.5

What should I do with my skincare?

The skincare approach is minimal therapy, which gives the word "routine" considerably less paperwork. There are two approaches: water only cleansing with facial products paused, or a minimal routine using a gentle cleanser and moisturiser. Follow the approach agreed with your clinician rather than combining them into a larger routine.12

1. 1Review your facial products and medicines with your clinician, especially any steroid cream used on the rash.
2. 2Pause cosmetics and facial creams unless your healthcare professional advises otherwise. For the water only approach, wash with water until the condition resolves.
3. 3If a cleanser is part of your plan, use a mild cleanser morning and evening. Choose fragrance free products without exfoliants, and avoid heavy, oil based facial creams.
4. 4Leave spots alone rather than picking or squeezing them.
5. 5After the rash clears, reintroduce skincare gradually, one product at a time. A soap substitute and an unperfumed moisturiser can be useful for dry or sensitive skin.

Water only cleansing needs no cleanser bottle, which settles that particular shopping decision.2

If sunscreen or makeup remains part of your plan, water based formulations are an alternative to oil based facial products. Cosmetics and sunscreens can themselves trigger perioral dermatitis, so include them when reviewing what touches the affected area.4

Should I stop hydrocortisone or another steroid?

Do not start hydrocortisone to treat suspected perioral dermatitis. Facial steroids can briefly make the rash look better, then leave it more extensive and inflamed. Stopping a steroid can also cause a rebound flare. If you already use a prescribed facial steroid, ask your prescriber how to withdraw it; some cases need a gradual reduction over two to three weeks. Discuss medically necessary steroid tablets, inhalers or nasal treatments with the prescriber rather than changing them yourself.14

What treatment can a doctor prescribe?

For milder cases, prescribed creams or gels can help. Options include topical antibiotics such as metronidazole or erythromycin. Azelaic acid is another option, and pimecrolimus is a nonsteroid anti inflammatory treatment. Topical treatment is not enough for every case; more severe or persistent disease can need oral medication.15

Oral antibiotics include doxycycline, lymecycline and erythromycin. These help reduce inflammation as well as bacteria. Your clinician chooses the medicine and course, rather than using a standard skincare schedule. If treatment is essential during pregnancy, erythromycin is an option for the prescriber to consider. Children also develop perioral dermatitis, so a child's treatment needs its own clinical assessment.245

How long does it take to clear?

The rash usually improves and clears over several weeks of treatment, but the antibiotic course can last longer than the visible rash. Most people need antibiotics for two to three months, and persistent cases can need a longer course. Some cases settle without medication. Recurrence is possible, even after successful treatment.12

When should I see a GP?

Arrange an assessment if you are unsure what the rash is, it persists despite reducing irritating products, or you need help changing a prescribed steroid. Tell the clinician which creams, cosmetics and medicines you use. If treatment is not helping, return for review: oral treatment or a dermatology assessment can be the next step. In NHS Greater Glasgow and Clyde, treatment before referral is part of the dermatology referral process.13