Perioral Dermatitis: Symptoms, Causes, and Treatment in the UK

Perioral dermatitis is a common skin condition characterised by a red, bumpy rash that develops predominantly around the mouth. Although it may resemble acne or rosacea, it is a distinct inflammatory disorder. In some cases, the rash can also appear around the nose or eyes (periorificial dermatitis), but the area immediately surrounding the lips is the most frequently affected site.

This condition primarily affects women aged between 20 and 45, though it can occur in men and children. While the exact cause is not always clear, it is widely recognised within UK clinical practice as being closely linked to the use of topical corticosteroids. The rash is generally not contagious but can be persistent and distressing for those experiencing it.

Identifying perioral dermatitis involves looking for specific patterns on the skin. The rash usually appears as a cluster of small, red, or pinkish bumps. These may look like tiny spots (papules) or whiteheads filled with fluid (pustules). The skin underneath and around these bumps often becomes red and scaly.

Key characteristics include:

• Location: A clear 'border' of normal-looking skin is often visible immediately around the lips (the vermilion border).
• Sensation: The area may feel itchy, tight, or have a mild burning or stinging sensation.
• Texture: The skin often feels dry or flaky in the affected areas.
• Distribution: While focused on the chin and upper lip, it can spread to the nasolabial folds (the lines from the nose to the corners of the mouth).

Unlike acne, perioral dermatitis does not typically feature 'blackheads' or 'whiteheads' in the traditional sense, and unlike eczema, the primary lesion is a small bump rather than a flat, dry patch.

The precise cause of perioral dermatitis is not fully understood, but several triggers have been identified through NHS experience and dermatological research. The most common culprit is the use of topical steroid creams. Patients often apply a mild steroid for a different skin issue, only to find that once they stop using it, a perioral rash flares up, leading to a cycle of dependency on the steroid.

Other potential triggers include:

• Cosmetics and Skin Care: Heavy moisturisers, paraffin-based products, or certain foundations can fluctuate skin flora and clog pores.
• Fluoridated Toothpaste: Some individuals find that the fluoride in their toothpaste irritates the skin around the mouth.
• Hormonal Factors: Flare-ups are sometimes noted during pregnancy or when using oral contraceptives, suggesting a hormonal link.
• Environmental Irritants: Wind, UV light, and certain facial cleansers can exacerbate the inflammation.
• Nasal Sprays: Steroid-containing nasal sprays used for hayfever can sometimes leak onto the skin, triggering a localized reaction.

In most cases, a clinical diagnosis can be made by a GP or dermatologist simply by examining the skin. No specific blood tests or biopsies are usually required unless the diagnosis is uncertain or the rash is not responding to standard treatments.

A GP will typically ask about your medical history, specifically focusing on your use of facial creams, steroid treatments, and recent changes in your skincare routine. It is important to be honest about steroid use, even if the cream was bought over-the-counter or used for a long time, as this is vital for planning the correct management strategy.

Treatment for perioral dermatitis requires patience, as the rash can take several weeks or even months to clear. The first and most critical step is the 'zero-therapy' approach.

Zero Therapy

This involves stopping all topical steroid creams and avoiding heavy cosmetics or moisturisers on the affected area. It is important to note that when you stop using a steroid cream, the rash may initially look worse (a 'rebound' effect) before it starts to improve. You should use only water or a very mild, soap-free cleanser to wash your face.

Prescription Medications

If the rash is persistent, a GP may prescribe the following:

• Topical Antibiotics: Creams or gels containing metronidazole or erythromycin can help reduce inflammation.
• Oral Antibiotics: For more severe cases, a course of tetracycline, doxycycline, or lymecycline may be prescribed for 6 to 12 weeks. These are used for their anti-inflammatory properties rather than just for killing bacteria.
• Calcineurin Inhibitors: Non-steroidal creams like pimecrolimus may be used to help manage the inflammatory response without the risks associated with steroids.

Managing perioral dermatitis at home involves lifestyle adjustments to prevent further irritation. Follow these UK-recommended self-care steps:

• Switch Toothpaste: Consider using a non-fluoridated toothpaste temporarily to see if symptoms improve.
• Avoid Scrubs: Do not use facial exfoliants or harsh scrubs while the rash is active, as these damage the skin barrier.
• Sun Protection: Use a lightweight, non-greasy sunscreen, as UV light can worsen the condition for some.
• Avoid Makeup: Try to go without foundation or concealer on the affected area until the skin has completely healed.

If you have a rash around your mouth that is not improving with basic hygiene or has appeared after using a steroid cream, you should seek medical advice. An online GP can provide a convenient consultation to assess your skin via video or high-quality photographs.

You should consult a GP if:

• The rash is spreading toward your eyes.
• The area is painful, intensely itchy, or leaking fluid.
• The condition is causing you significant distress or affecting your confidence.
• Self-management steps have not worked after two to four weeks.

A GP can offer a professional diagnosis, prescribe the necessary anti-inflammatory antibiotics, and provide a treatment plan to manage the 'rebound' effect safely.