A Top Acne Mimicker - Perioral Dermatitis
If you’ve noticed a persistent, bumpy, red rash around your mouth, nose, or eyes—especially one that seems to get worse with steroid creams or heavy skin products—you may be dealing with a condition called perioral dermatitis, also referred to more broadly as periorificial dermatitis. It’s a common condition I see in clinic, especially in women and children, and it can be both frustrating and confusing because of its ability to mimic acne. Typical acne treatments don't help, and other options commonly used like topical steroids seem to help at first but ultimately make things worse.
What Exactly Is Perioral Dermatitis?
Perioral dermatitis is a type of inflammatory facial rash that typically presents with:
- Clusters of small red or pink papules (bumps), sometimes with pus (pustules)
- Fine scale or dry patches in some areas
- Sparing of the skin immediately next to the lips (a telltale sign)
- Burning, stinging, or tightness, but usually not significant itching
The condition most often shows up around the mouth (perioral), but it can also affect the skin around the nose (perinasal) and eyes (periocular)—which is why dermatologists now prefer the term “periorificial dermatitis.” The rash can occasionally spread to the cheeks, forehead, or chin.
In children, we sometimes see a variant called granulomatous periorificial dermatitis, where the bumps are firmer, flesh-colored to reddish-brown, and not associated with scaling or pustules.
What Causes It?
The exact cause isn’t fully understood, but we know several common triggers play a role:
1. Topical corticosteroids
The most common culprit. Many patients report using a steroid cream (often for something like eczema or irritation), which initially helps, but leads to flares once they try to stop. This rebound phenomenon is a classic sign of perioral dermatitis.
2. Inhaled or nasal steroids
If you're using steroid sprays for allergies or asthma, the mist settling on the skin around your nose or mouth can contribute to flares.
3. Overuse of skincare products
Heavy moisturizers, occlusive makeup, and thick sunscreens can disrupt the skin barrier and trigger inflammation.
4. Fluoridated toothpaste
This isn’t a problem for everyone, but in sensitive individuals, switching to a fluoride-free toothpaste may help.
5. Environmental and lifestyle factors
Sunlight, hot water, wind exposure, and stress can all make perioral dermatitis worse. Hormonal fluctuations and birth control pills may also play a role in some women.
What It’s Not (But Often Gets Confused With)
Acne: Unlike acne, perioral dermatitis usually doesn’t involve blackheads or deep cysts. Also, it tends to spare the typical acne zones like the jawline and forehead.
Rosacea: Rosacea affects the central face (cheeks, nose) and often includes flushing and visible blood vessels (telangiectasias).
Eczema: Perioral dermatitis may look a little dry and irritated, but it doesn’t behave like classic eczema and worsens with steroid creams over time.
Seborrheic dermatitis: This affects areas like the eyebrows, nasolabial folds, and scalp—less commonly around the mouth.
How We Treat It
Step 1: Identify and Remove Triggers
This includes stopping:
Topical corticosteroids (we may taper if you’ve been on them long-term)
Thick moisturizers or irritating cosmetics
Fluoridated toothpaste (try switching for a few weeks)
Harsh cleansers or exfoliants
We call this “zero therapy”—essentially pressing pause on your current skincare. This alone can improve mild cases over a few months.
Step 2: Topical Treatments
For mild to moderate cases, we often prescribe:
Metronidazole cream/gel (typically used for rosacea)
Topical erythromycin
Pimecrolimus (Elidel) or tacrolimus (Protopic) – These are non-steroidal anti-inflammatory creams
Improvement usually starts within 2–4 weeks, but full resolution may take 6–8 weeks.
Step 3: Oral Antibiotics (if needed)
Moderate to severe cases, or those that don’t respond to topicals, may require:
Doxycycline, tetracycline, or minocycline (for adults and teens)
Erythromycin or azithromycin (for kids or patients who can’t take tetracyclines)
These antibiotics are used for their anti-inflammatory properties, not because this is an infection. Treatment courses usually last 4–8 weeks.
Step 4: Maintenance and Prevention
Once the rash clears, we reintroduce skincare products gradually—starting with one new product per week.
Stick to:
Fragrance-free, non-comedogenic moisturizers
Gentle, non-soap cleansers
Lightweight sunscreen (zinc oxide-based options work well)
If steroids are needed for other skin conditions in the future, we try to avoid the face—or use the lowest strength possible, for the shortest duration.
What About Recurrence?
Perioral dermatitis usually resolves with proper treatment and trigger avoidance. Recurrence is uncommon unless you're re-exposed to the inciting factors (especially topical steroids). If you’re prone to this condition, we’ll help you build a skincare plan that’s safe for your skin long term.
In Summary
If you’re dealing with a stubborn rash around your mouth, nose, or eyes, don’t ignore it or try to “treat through it” with more steroids or acne products. These often worsen the problem. With the right diagnosis and treatment plan, perioral dermatitis responds well—and most patients see significant improvement within weeks. Come see us at Pure Dermatology, where you'll get expert care by a board-certified dermatologists who can help you develop a treatment plan that works for your skin.
