Treatment: Discontinue steroids, start antibiotics
If left untreated, perioral dermatitis rarely resolves on its own and will have a fluctuating course, punctuated by flares, that will last for years. The prognosis is excellent, however, once appropriate therapy is instituted; recurrence after treatment is low.5
Cessation of topical steroids is a mainstay of treatment6,7 (strength of recommendation [SOR]: B). High-potency topical steroids can cause short-term improvement of the rash; removal will cause short-term worsening of symptoms. It’s best, then, to switch your patient to a less potent steroid, and then gradually discontinue the steroid3 (SOR: C). Doing so can help the patient to avoid a rebound flare and the temptation to restart the steroid for short-term relief.
It’s also a good idea to tell the patient to stop using other causative agents, such as moisturizing creams, blush, foundation, oral contraceptives, and fluorinated toothpaste6 (SOR: C).
Several antibiotic regimens are successful in the treatment of perioral dermatitis. Tetracycline 250 mg twice daily, minocycline 100 mg daily, or doxycycline 100 mg daily for 2 to 3 weeks is the initial treatment. The treatment course may last up to 6 weeks8 (SOR: B). For children, pregnant women, or patients with allergies to certain antibiotics, erythromycin 250 mg twice daily for up to 6 weeks is also an option7 (SOR: C).
Topical treatments can also be used, but often take longer and have been shown to be less effective than oral therapies. Metronidazole 0.75% gel applied twice daily for 14 weeks or 1% cream applied twice daily for 8 weeks has been shown to be useful9,10 (SOR: C). Erythromycin 2% gel applied twice daily for several months is also effective7 (SOR: C).
Discontinuing the steroid was a challenge for our patient
We told our patient to discontinue her steroid cream, and we started her on metronidazole gel. She returned with significant worsening of her rash, including swelling and erythema. We therefore prescribed a brief course of prednisone for short-term relief while she was started on oral doxycycline. After 6 weeks of oral doxycycline therapy, her rash resolved. At a 6-month follow-up, the patient had experienced no further recurrence of the rash.
CORRESPONDENCE Marc Babaoff, MD, MAHEC Family Medicine Residency Program, 118 W. T. Weaver Boulevard, Asheville, NC 28804; Marcus.babaoff@mahec.net