Diagnosis: Perioral dermatitis

The patient was diagnosed with perioral dermatitis (POD). This chronic condition most commonly affects women 16-45 years of age but has been seen in children of either gender aged 7 months to 13 years. Periocular and perinasal lesions will often be present among children presenting with POD. While POD is a benign condition, the negative effect on appearance, unpredictability of flare-ups, and the location of lesions make it frustrating and annoying.

Typically presenting as small erythematous papules and papulopustules, POD lesions are also found on the chin, nasolabial folds, and periorbital areas (but are often absent in the narrow strip of flesh surrounding the vermilion). The eyelids may also be affected. The eruption may be pruritic, and some patients may develop skin sensitivity, especially to sunlight. Flare-ups sometimes occur during periods of stress or seasonal allergies.

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The pathogenesis of POD has been related to dry skin and barrier-function impairment but is still poorly understood. A variety of hormonal, infective, and occlusive agents, including various steroids, contraceptive pills, moisturizing creams, and toothpastes, have been associated with this condition. Renal transplant recipients and patients with ulcerative colitis receiving systemic corticosteroids have developed POD, as have children using inhaled steroids to control asthma.

Without treatment, POD may persist for months or years, especially among frequent users of topical steroids. The disease has been reported in North America, Western Europe, Scandinavia, and Australia.

The greatest challenge in the diagnosis of POD is ruling out similarly presenting conditions, such as acne, folliculitis, impetigo, or acneiform rosacea. Contact allergies must also be excluded, and topical therapies in current use must be discontinued. Once treated successfully, the condition does not usually recur.

Both topical and systemic treatment options are available for POD. Flare-ups may be mitigated or prevented by substituting a lower-potency topical steroid, such as hydrocortisone cream. Other topical options include 1.5%-2.0% erythromycin solution (alone or in combination with hydrocortisone cream), metronidazole cream (1%) or gel (0.75%), sulfacetamide and hydrocortisone, tetracycline, clindamycin, isotretinoin (for granulomatous POD), or azelaic acid. Patients with POD tend to have unusually sensitive skin, however, so topical modalities may not be easily tolerated.

The most effective antibiotic oral therapy for POD is tetracycline. Unfortunately, the use of antibiotics in children younger than 8 years and in pregnant women (the groups within the age range likely to suffer from POD) is not recommended. Tetracycline has been known to cause nausea and vomiting and may also be contraindicated due to resultant phototoxicity. Other systemic alternatives include doxycycline, erythromycin, minocycline, and combinations of sulfamethoxazole and trimethoprim.

Complete resolution of POD lesions has been seen with combinations of oral tetracycline and topical sulfacetamide-hydrocortisone lotion. Although less effective, erythromycin (oral or topical) or topical metronidazole may be substituted for tetracycline in this combination therapy. It must be noted, however, that the FDA has not approved tetracycline, erythromycin, or topical metronidazole for POD.   

Patients may refuse oral and topical antibiotics, so photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA) (Levulan Kerastick) and blue-light activation (BLU-U) is a valid alternative modality for POD. Topically applied ALA (a porphyrin precursor in the heme biosynthesis pathway) penetrates the skin and is converted to protoporphyrin IX (PpIX), which forms cytotoxic singlet oxygen when activated by a light source. Because ALA penetrates stratum corneum composed of abnormal epidermal cells more rapidly than stratum corneum composed of normal epidermal cells, ALA-induced PpIX accumulates preferentially in abnormal cells, providing a measure of specificity for ALA PDT. The treatment, which is safe and effective, provides a measure of cosmetic benefit (i.e., reduced sallowness, dyspigmentation, and wrinkles) that may appeal to adult patients.

Figure 1. After treatment, the lesions showed vast improvement.Although four weekly sessions of ALA PDT have been shown to be more effective than clindamycin phosphate gel for treating POD, patients treated with ALA PDT must avoid sunlight for 24-48 hours after treatment. 

Our patient was successfully treated with four consecutive once-weekly sessions of PDT in which ALA was allowed to incubate for 30 minutes, then exposed to blue light for eight minutes. Follow-up one month after the final treatment showed almost complete clearance of lesions (Figure 1).

Mr. Hopson works at North Valley Dermatology in Chico, Calif.

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