Perioral dermatitis: Why are there rashes around my mouth?

Ep 37: Rashes Around Your Mouth? Perioral Dermatitis Causes & Treatment

Hi guys, this is Dr. Teo Wan Lin of TWL Specialist Skin and Laser Centre and welcome to my podcast Dermatologist Talks: Science of Beauty. In this week’s dermatology flash briefing, we’re going to be talking about perioral dermatitis. Perioral dermatitis refers to a condition affecting the area around the mouth. Literally peri-oral, and also synonymously known as periorificial dermatitis, which means that it can appear over the other orifices as well.

Characteristics of perioral dermatitis

In the case of periocular dermatitis, the rashes appear around the eyes. on the eyelids and around the nose area. These are all the orifices on the face, and is refer to as a form of eczema affecting the orifices. Hence, the term periorificial dermatitis, which is synonymous with perioral dermatitis. 

Dermatitis describes the breakdown of skin barrier physically seen as redness, flaking and bumps on the surface of the skin. There are also subjective sensations such as sensitivity to external triggers, environmental changes and internal emotions of stress. Sometimes also with illnesses such as flu or diarrhea, we find that perioral dermatitis can act up as well. Fluctuations in the hormonal cycle for women around the time of their menstrual cycle. All these can cause perioral dermatitis to flare.

What are the main triggers of perioral dermatitis?

The most common trigger for perioral dermatitis in a genetically susceptible individual would be topical creams. The main causes of contactants that trigger perioral  dermatitis would be topical steroids. These are often inappropriately used. Either illegally purchased over the counter or inappropriately used low-potency topical steroids. One example is hydrocortisone over a long period of time without medical supervision. Perioral dermatitis can also worsen by the application of moisturizers and sunscreens. Both of which are essential components in one skincare regimen, which makes the treatment of perioral dermatitis extremely challenging.

Rashes around the mouth? What are the signs and symptoms?

Before moving on to the treatment options for perioral dermatitis, we’re going to be talking about how to identify it. And if you think that you have it, what you can do about it. The clinical presentation must be distinguished from acne. It is a common mimic of acne and another condition – rosacea. This is because both of these conditions can present with clusters or red bumps around the nose and mouth area. Most distinctively, acne has opened comedones and close comedones, which refer to black heads and white heads in colloquial terms.

These also mix with the presentation of pustules on your skin in perioral dermatitis. Pustules are also common, but there is almost always background redness, dryness and flaking. This redness must be distinguished from that to rosacea, which also affects the cheeks and the forehead. In perioral dermatitis, however, it tends to localize at areas around the mouth, nose and eyelids. Notably, it also spares specific areas such as the margin around the lips. 

Common misdiagnosis

For adult acne, it is sometimes confusing because hormonal acne tends to affect the jaw line (U-zone of the face). Physiologic acne, which starts in teenage years affects the T-zone of the face, the nose and forehead area, and a lot of adult acne sufferers continue to have seborrhea at those areas, the excess production of oil. Because perioral dermatitis affects the area around the mouth, it can sometimes be confused for hormonal acne. However, the symptoms are quite important and different. Individuals with perioral dermatitis complain of stinging sensations and the inability to use any form of cosmetics. Their usual makeup, cleansers or sunscreens cause the skin to sting and flare up unlike in acne or rosacea. 

Treatment for rashes around the mouth

It’s also key to note that both eczema and perioral dermatitis can coexist, as it can also coexist with acne. Most importantly, perioral dermatitis is rather challenging to treat. Also, because most dermatological conditions treat with topicals first, it presents a unique treatment challenge because perioral dermatitis itself can be triggered off by topical medications. So, the first line treatment for mouth perioral dermatitis, we often prescribe topical antibiotics. However, these are of limited use because of the issue of antibiotic resistance. It is applicable because part of the etiology of perioral dermatitis pinpoints to a certain bacteria – fusobacteria, and changes in the skin microbiome.

In my position paper on biofunctional textiles and maskne, I postulated that biofunctional textiles applied over the skin in the form of a reusable fabric mask, can present therapeutic opportunity to treat the skin microbiome. I think this is also relevant in the treatment of conditions such as perioral dermatitis which we know is related to the skin microbiome.

Next, we want to talk about the mainstay of treatment for moderate to severe perioral dermatitis. For individuals who are mostly treated with oral medications, we dispense low doses (sub-antimicrobial doses) of oral antibiotics such as tetracycline, doxycycline, being one of the commonest tetracyclines, which is used in clinical practice. Erythromycin for individuals who are intolerant to doxycycline. Now, individuals who fail treatment with oral antibiotics then sometimes low dose isotretinoin, or by the brand name accutane, can be prescribed and will help the condition to a certain extent.

Skincare tips for perioral dermatitis

Moving on, there are specific contactants and triggers to avoid in your skincare regimen if you suspect that you have perioral dermatitis. First of all, your most important skincare step is cleansing. As we alluded to earlier, the change in the skin microflora is responsible for some of the inflammation that occurs in perioral dermatitis.

Cleansing your skin is important because it restores this microbiome balance. Gentle cleansing is better than stringent cleansing. If you are the sort of person that likes your skin feeling squeaky clean after you cleanse it, just know that this is actually going against the principles of dermatological science. Because, in order for the skin to maintain its healthy barrier function, there has to be a layer of lipids that sit on top of the skin, trapping moisture within the topmost layer of the skin (stratum corneum) to prevent trans epidermal water loss. 

Do you have to moisturize if you have perioral dermatitis?

The second most important step in your skincare regimen if you have perioral dermatitis is moisturizing. It seems like a trick question, do you have to moisturize if you have perioral dermatitis. Because, we’ve said before that moisturizers can actually make your condition worse. But the truth is because it is a form of dermatitis which means that there is a breach in the skin barrier, completely skipping a moisturizer means that you’re setting yourself up for more complications and a more prolonged cause of the condition because your skin barrier is critical and preventing the external allergens environmental triggers from causing your skin to get worse in terms of inflammation.

Importantly, we want to focus on the type of moisturizer. Serums in this case are more beneficial than ointments or heavy creams. I prefer serums and lotions as the key moisturizing vehicles in the adjuvant therapy of perioral dermatitis. The active ingredients are crucial here. Hyaluronic acid (sodium hyaluronic), being the chemical name of the compound, is naturally in your skin’s dermis and is responsible for a lot of the cell communication that goes on what we call cell talk. 

Skin barrier function

It’s important to ensure that whatever you apply on your skin is absorbed and goes on to repair the skin barrier so that it can help the skin preserve his protective function. The gold standard of moisturizer therapy in eczema is now termed as a prescription emollient device. This is essentially a lipid-balanced moisturizer with an anti-inflammatory component that is non-steroidal. This term was first coined by a pediatric dermatologist Lawrence Eichenfield to describe the type of steroid sparing therapy that could improve the outcome of treatment of eczema patients. So, when you apply that to the treatment of facial eczema or other forms of dermatitis, we can expect the skin barrier function to improve and overall a more resilient skin to handle inflammation arising from pre-existing dermatological conditions such as perioral dermatitis or even external contractions are much better. 

moisturizer perioral dermatitis

The Multi-CERAM Moisturizer is an ultra intensive skin moisturiser for total skin barrier repair with pharmaceutical grade ingredients. It is dermatologist-formulated to treat eczema, dry sensitive skin and to prevent skin ageing.

Sun protection

It is a delicate balance when you are recommending a skincare regimen for an individual suffering from perioral dermatitis. Sunscreen is a key component in every skincare regimen because this disease, interestingly, is also a sun sensitive (photosensitive) condition. Another photosensitive condition that occurs on the face and looks a lot like the clinical presentation of perioral dermatitis, is seborrheic dermatitis. Seborrheic dermatitis, colloquially known as dandruff, is caused by a yeast known as malassezia, which primarily lives on your scalp. It feeds off the greasy, oily environment of your scalp, but when it colonizes your skin on the face, you get redness over areas such as the eyebrows, around the nose area (nasolabial folds).

The SunProtector is formulated with physical blockers like titanium dioxide and zinc oxide that effectively blocks UV radiation. Portulaca Oleracea (Purslane) and Oligopeptides included are potent antioxidants which actively fight free radicals generated by UV exposure as well as airborne pollutants – for comprehensive protection.

It is also important that we do not misdiagnose these conditions. Perioral dermatitis and seborrheic dermatitis are examples of photosensitive facial dermatosis that would benefit from sun protection. The idea of using a dermatologist-recommended sunscreen on an individual who suffers from perioral dermatitis is actually quite tricky because the vehicle of all effective sunscreens is actually an oil base. This enables the UVA component of the sunscreen to remain stable and active. In the case of an individual perioral dermatitis in the acute treatment phase, I often ask them to simply avoid exposure to sun. With the advent of the UPF textiles, for example, what we incorporated in our biofunctional textile, under the biomaterials arm of Dr. TWL Dermaceuticals, is also a potential avenue for sun protection benefits of a textile when topical sunscreen is contraindicated. 

Perioral dermatitis and maskne

Maskne is just one of the conditions that can arise from wearing a face mask. We’ve spoken about facial eczema in this case, perioral dermatitis, we’ve briefly talked about rosacea as well as seborrheic dermatitis. All these are dermatosis on facial skin, which exacerbates by textile skin friction, as in the case of wearing a face mask and also by changes in the skin microenvironment. This is where the concept of biofunctional textiles is particularly relevant. Because, they function as topical antibiotics, but without the side effects of antibiotic resistance, which is what we observe with topical antibiotic therapy, say the treatment of rosacea, acne and perioral dermatitis.

mask for maskne

The CUIONS Anti-Maskne Mask contains copper nanoparticle impregnated fabric in 2 layers for enhanced filtration. It is rigorously lab tested for the active release of copper ions that are biocidal and certified for anti-microbial functions to actively prevent and treat mask acne. 

What products should I avoid for my skin? Can I still wear makeup if I have perioral dermatitis?

Dr.TWL: There is a special category of what to avoid in your skincare and contactants when it comes to your regimen if you have been diagnosed with perioral dermatitis. First of all, toothpaste. Avoid fluorinated toothpaste and mint toothpaste. In particular, look for children’s brands of toothpaste. SLS-free brands are also more helpful and those who suffer from perioral dermatitis generally tolerate it better. Secondly, non-dermatologist recommended products may trigger off a flare up in your skin condition.

When it comes to makeup, it is important for you to treat your condition properly, have it under control before you start experimenting with makeup. Now, it is of course relevant for cosmetic reasons that you would want to conceal your facial rashes. In my practice, we have a colour correction service, which is based on the colour wheel using green to counteract the background redness of perioral dermatitis in a formula that does not irritate the skin and does not cause flare ups. It is an emulsion formula that also contains anti-inflammatory ingredients for skin healing properties. CC creams may be more beneficial when compating to traditional foundations if you have perioral dermatitis. CC creams tend to have added antioxidant ingredients as well as emollient properties. 

cc cream

The Celltalk CC Cream features 7 power anti-oxidant ingredients in a formula that soothes and anti-ages sensitive skin while covering pigmentation and blemishes.

Summing up

In closing, we want to summarize the few things we’ve learned about perioral dermatitis. First of all, it is a fairly common condition that’s often misdiagnosed as acne, hormonal acne and rosacea. It is a very troubling condition which can lead to long term scarring and worsening sensitivity if left untreated. Medical treatment is absolutely essential for perioral dermatitis. There is no cosmetic or aesthetic intervention in the form of lasers or peels that would be able to treat the condition effectively. It is important to seek the help of an accredited dermatologist when you’re managing this condition, which needs to be followed up long term as well. Medications are often required in the treatment of perioral dermatitis. 

We have covered some of the important skincare tips that we can implement if you suspect you have perioral dermatitis, triggers to avoid and also what symptoms should prompt you to see a dermatologist for an opinion. That’s it for today’s episode of Dermatologists Talks: Science of Beauty. Thank you for joining me, you can follow me on my Instagram @drteowanlin. The full podcast transcript is on the website and I wish you all a wonderful week.

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