John R. Tkach, M.D.
300 North Willson, Suite 203B
Bozeman, MT 59715
(406) 587-5442

Perioral Dermatitis

Patient Information Sheet

Perioral dermatitis is a face rash that occurs mostly around the mouth. It looks like a combination of mild acne and a mild face rash. The areas usually are a little red and scaly with red bumps. Unlike acne you cannot squeeze blackheads out of the little bumps. It is most common in young women, but I have seen several men with perioral dermatitis.

The cause of perioral dermatitis is unknown. It was first described by Dr. Henry Lewis of Denver in 1956. Dr. Lewis observed that it occurred in young women taking birth control pills when they went out in the sun. His treatment was to have people stop using birth control pills. That did help. The problem was that, as time went on, dermatologists noticed that many patients with perioral dermatitis were not taking birth control pills. So, birth control pills may make perioral dermatitis worse, but don't cause it.

Then we went through a period of eight or nine years in which our thinking was dominated by a notion from England that perioral dermatitis was due to fluoride. Dermatologists there observed that cortisone creams that contained cortisone with fluoride made perioral dermatitis worse. Fluorinated cortisone creams are stronger than those without fluoride. Back then, we treated perioral dermatitis by stopping fluorinated cortisone creams, fluorinated toothpastes, and fluorinated water. Stopping fluorinated water and toothpaste did not make any difference. But, the fluorinated cortisone creams did make it worse. This notion was a consequence of how the socialized medicine system in England works. In that system, you do not just go to a dermatologist on your own. You must see your government assigned family doctor. To see a dermatologist, a patient must be referred by the family doctor. So all the perioral dermatitis patients seen by the dermatologists had already been seen by the family doctors and were using strong fluorinated creams for two years or more while waiting for the chance to see a dermatologist.

A confusing part of this is that the strong fluorinated cortisone creams made the rash better for a while. After about four months, patients were finding that they had to use the medicine more and more to control the rash. If they stopped, the rash got ten times worse. So the medicine made the rash better for a short time, but in the long run made it worse.

Sunlight is supposed to make perioral dermatitis worse. My experience is different. About a fourth of patients get worse from sunlight, and sunscreens help. About as many get better with sunlight. For half of my patients, sunlight does not make it better or worse.

What Is Perioral Dermatitis?

What we are left with is a somewhat acne-like face rash mostly around the mouth and sometimes around the eyes that occurs mostly in women. It is made worse by birth control pills and strong fluorinated cortisone creams. The role of sun is variable.

I think perioral dermatitis is a variant of adult acne, acne rosacea. Teenage acne has a lot of blackheads and whiteheads. In adult acne, there usually are few or no blackheads. In adult acne, people tend to get red bumps, pustules, and cysts. I think perioral dermatitis is either a mild form of adult acne or a transition phase between teenage acne and adult acne.

What Is the Outlook?

About a third of patients have a flare up that just won't go away. It lasts for five or six years or longer. About a third have a fairly severe flare-up for six months. Then it goes away for two or three years and comes back. About a third will have a flare up for about two months. Then it goes away for four months, and tends to come and go.

Treatment

I see a lot of people with perioral dermatitis. I have tried many treatments. I did a chart review of all the patients I had seen in my first nine years of practice. I was surprised to discover that I see as many or more people with perioral dermatitis as I see with warts.

The best treatment has been tetracycline pills or minocycline pills. You take one pill a day on an empty stomach for a month. Tetracycline is pretty safe at this dose. It is completely destroyed by food. So, you must take it with your stomach empty for an hour before and after you take the pill. Tetracycline could make you more sensitive to sunburn. Be sure to use a sunscreen if you are going to be in the sun such as skiing or swimming. Rarely tetracycline can cause a yeast infection of the vagina. This is characterized by a thick white cheesy vaginal discharge that causes itching around the vagina. If that happens, stop the tetracycline and let me know.

Minocycline is super tetracycline. It gets into he skin ten times better. That means that instead of taking 250 mg or 500 mg of tetracycline a day, you can take 50 mg of minocycline. You can take it with food. It is less likely to cause upset stomach. It is less like to cause yeast infections.

At the same time, use a mild, non-fluorinated cream such as Westcort or Locoid Lipocream. On the face, we must be concerned about safety. That's why we use a mild cortisone cream. To get strength out of it, wet the skin before you put it on. Wet the rash areas and rub in the medicine once or twice a day. That way you get the safety and the effectiveness. As the rash improves, try to decrease the cortisone cream to once a day. Most people tell me that they can eventually get by with once a day.

For the first month, use both the cream and the pills. After the first month, you will run out of pills. Use just the cream. See me at two months. We will have to see if you can get by with just the cream or if you will need more pills. About 70% of my patients are able to get by without the pills after the first month.

The information provided in these patient information sheets is offered for general informational and educational purposes only; it is not offered as and does not constitute medical advice. In no way are any of the materials presented meant to be a substitute for professional medical care or attention by a qualified practitioner, nor should they be construed as such.

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