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Rosacea Perioral Dermatitis [RPD]

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There are authoritative sources who classify Perioral Dermatitis as a rosacea variant. The RRDi recognizes PD as Rosacea Periorial Dermatitis [RPD] as a rosacea variant. 

<begin Excerpt from Rosacea 101: Includes the Rosacea Diet, pages 10, 11 by Brady Barrows, with permission from the author>

Perioral Dermatitis

“Perioral dermatitis (POD) is a chronic papulopustular and eczematous facial dermatitis. It mostly occurs in women, although a distinct papular variant occurs in children. The clinical and histologic features of the lesions resemble those of rosacea. Patients require systemic and/or topical treatment, an evaluation of the underlying factors, and reassurance.… The etiology of perioral dermatitis is unknown; however, the uncritical use of topical steroids for minor skin alterations of the face often precedes the manifestation of the disease” [47]

“Histologically, it is indistinguishable from rosacea …” [48]

“PD is characterized by a skin barrier disorder of facial skin. It differs from rosacea in that it involves a significantly increased TEWL and features of an atopic diathesis. However, it remains disputed as to whether PD is an individual skin disease or a subtype of rosacea in atopic patients.” [49]

“Ackerman has stated his belief that, histologically, this condition is the same as rosacea. He says that ‘like rosacea, perioral dermatitis is fundamentally an inflammatory process involving hair follicles. Initially, both conditions are folliculitis that progresses to granulomatous folliculitis and dermatitis.’” [50]

Perioral dermatitis is a red, bumpy rash around the mouth and on the chin that resembles acne or rosacea … Perioral dermatitis can be hard to separate from rosacea, but symptoms including tiny blisters and skin scaling can help make the distinction. Other symptoms of rosacea must be present for that diagnosis to be made instead of perioral dermatitis.” [51]

“Perioral dermatitis (POD) is a chronic papulopustular and eczematous facial dermatitis. It mostly occurs in women, although a distinct papular variant occurs in children. The clinical and histologic features of the lesions resemble those of rosacea … Histologic findings are similar to those of rosacea …” [52]

“You won’t see comedones (whiteheads and blackheads), cysts (boil-like lesions), or scarring, as you would if you have acne, nor will you see the typical flushing of rosacea.” [53]

“The cause of perioral dermatitis is unknown. But some dermatologists believe it is a form of rosacea…” [54]

“Perioral dermatitis (POD) is a chronic papulopustular facial dermatitis found in younger women and children. It appears to be a juvenile form of granulomatous rosacea.” [55]

Some authorities consider that perioral dermatitis is a circumscribed variant of rosacea.” [56]

Some experts consider this disorder to be a variant of rosacea.” [57]

“Perioral dermatitis is a distinct entity and not a variant of seborrhoeic dermatitis or rosacea …” [58]

“Although rosacea papules may appear in the perioral area, as noted earlier, perioral dermatitis without rosacea symptoms cannot be classified as a variant of rosacea. Perioral dermatitis is characterized by such stigmata as microvesicles, scaling, and peeling.” [59]

“Sodium sulfacetamide, penetrating antibacterial, in combination with hydrocortisone and sulfur, has enjoyed twenty years of remarkable safety, with outstanding efficacy and patient acceptance, in the prescription treatment of pustular acne and severe, refractory seborrheic dermatitis. Recently, this combination has been reported to be highly effective concomitant therapy for perioral dermatitis. Almost paradoxically, it achieves these desired goals without the excessive erythema and discomforting irritation associated with retinoic acid and benzoyl peroxide.” [60]

As already mention some clinicians consider perioral dermatitis to be a variant of rosacea. [61] It usually effects young females and results from topical steroid use. My gut feelings nominate perioral dermatitis as a rosacea variant but because of the controversy about this I am listing it also as a rosacea mimic. This is another example of the confusion in rosacea among dermatologists. There is no general consensus and much debating.

<end excerpt from Rosacea 101>

Periorol Dermatitis is a rosacea mimic and is considered in a differential diagnosis of rosacea. "Perioral” refers to the area around the mouth, and “dermatitis” indicates a rash or irritation of the skin. Usually Periorol Dermatitis is characterized by tiny red papules (bumps) around the mouth. The areas most affected by perioral dermatitis are the facial lines from the nose to the sides and borders of the lips, and the chin. The areas around the nose, eyes, and cheeks can also be affected. There are small red bumps, mild peeling, mild itching, and sometimes burning associated with perioral dermatitis. When the bumps are the most obvious feature, the disease can look like acne.

Compare images of acne, rosacea, perioral dermatitis and other similar rosacea mimics: DermIS 27 Images.

A research paper in 2004 said, "However, it remains disputed as to whether PD is an individual skin disease or a subtype of rosacea in atopic patients." [1] This is because the classification of rosacea into subtypes and variants remains a controversy. [2]

A dermatologist diagnoses perioral dermatitis by examination. No other tests are usually done. Sometimes, scraping or a biopsy of the skin is done. Occasionally, blood tests are ordered to eliminate other conditions that can look similar. A culture for bacteria may sometimes be needed to eliminate the possibility of infection.

Perioral dermatitis is a facial rash that tends to occur around the mouth. Most often it is red and slightly scaly or bumpy. Any itching or burning is mild. It may spread up around the nose, and occasionally the eyes while avoiding the skin adjacent to the lips. It is more rare in men and children. Perioral dermatitis may come and go for months or years. One of the most common factors is prolonged use of topical steroid creams and inhaled prescription steroid sprays used in the nose and the mouth. Overuse of heavy face creams and moisturizers are another common factor. Other factors include skin irritations, fluorinated toothpastes, or other dental fluorinated products. Some dermatologists believe it is a form of rosacea or sunlight-worsened seborrheic dermatitis.

Why perioral dermatitis occurs more frequently in young women is a quandary. However, it may sporadically affect men. Its exact cause is unknown. Perioral dermatitis is a difficult condition to treat effectively, often requiring several months of treatment.

"...A low-potency topical steroid may also be used to suppress the inflammation and to wean off the strong steroid. Perioral dermatitis in childhood is probably a juvenile form of rosacea..." [3]

Apparently the one study suggests that topical steroid use increases demodex mite density in perioral dermatitis. [4]

"Tacrolimus ointment is increasingly used for anti-inflammatory treatment of sensitive areas such as the face, and recent observations indicate that the treatment is effective in steroid-aggravated rosacea and perioral dermatitis." [5]

"Perioral dermatitis was diagnosed in 329 patients....In 80 patients demodex was discovered....Treatment with liquid nitrogen gives good results..." [6]

DermNetNZ page on PD

Other Sources

Perioral dermatitis (rosacea-like dermatitis)--adverse effects of externally applied steroid preparations
Urabe H. - 1978

The treatment of steroid-induced rosacea and perioral dermatitis.
Sneddon IB. - 1976

Perioral dermatitis and rosacea-like dermatitis: clinical features and treatment.
Urabe H, Koda H. 1976

End Notes

[1] Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis.

Dirschka T, Tronnier H, Fölster-Holst R.

Br J Dermatol. 2004 Jun;150(6):1136-41.

[2] Classification Of Rosacea Remains Controversial
article by Brady Barrows, RRDi Director

[3] Perioral dermatitis in children.
Laude TA, Salvemini JN.
Semin Cutan Med Surg. 1999 Sep;18(3):206-9.

[4] Density of Demodex folliculorum in perioral dermatitis.
Dolenc-Voljc M, Pohar M, Lunder T.
Department of Dermatovenereology, University Medical Centre Ljublana, Zaloska 2, SI-1525 Ljublana, Slovenia.
Acta Derm Venereol. 2005;85(3):211-5.

[5] Induction of rosaceiform dermatitis during treatment of facial inflammatory dermatoses with tacrolimus ointment.
Antille C, Saurat JH, Lübbe J.
Arch Dermatol. 2004 Apr;140(4):457-60.

[6] Perioral dermatitis--an allergic disease?
Arutjunow V., Hautarzt. 1978 Feb;29(2):89-91.

[47] Perioral Dermatitis eMedicine, Article Last Updated: Feb 7, 2007
Hans J Kammler, MD, PhD, Head of Unit for Dermatology, ENT, Ophthalmology, and Respiratory Diseases,
German Federal Institute for Drugs and Medical Devices
http://www.emedicine.com/derm/topic321.htm

[48] Perioral dermatitis in children.
Laude TA, Salvemini JN.
Semin Cutan Med Surg. 1999 Sep;18(3):206-9

[49] Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis.
Dirschka T, Tronnier H,Fölster-Holst R;
Br J Dermatol. 2004 Jun;150(6):1136-41

[50] Perioral Dermatitis eMedicine, Article Last Updated: Feb 7, 2007
Hans J Kammler, MD, PhD, Head of Unit for Dermatology, ENT, Ophthalmology, and Respiratory Diseases,
German Federal Institute for Drugs and Medical Devices
http://www.emedicine.com/derm/topic321.htm

[51] Dermatitis, The Merck Manuals Online Medical Dictionary, revision December 2006 by Peter C. Schalock, MD
http://www.merck.com/mmhe/sec18/ch203/ch203c.html

[52] Perioral Dermatitis eMedicine, Article Last Updated: Feb 7, 2007
Hans J Kammler, MD, PhD, Head of Unit for Dermatology, ENT, Ophthalmology, and Respiratory Diseases,
German Federal Institute for Drugs and Medical Devices
http://www.emedicine.com/derm/topic321.htm

[53] http://www.rosaceaguide.ca/basics/like_rosacea/perioral_dermatitis.html

[54] Perioral Dermatitis American Academy of Dermatology Pamphlet
http://www.aad.org/public/Publications/pamphlets/PerioralDermatitis.htm

[55] A case of granulomatous rosacea: Sorting granulomatous rosacea from other granulomatous diseases that affect the face.
Omar Khokhar MD, and Amor Khachemoune MD CWS Dermatology Online Journal 10 (1): 6 source >
http://dermatology.cdlib.org/101/case_reports/rosacea/khachemoune.html

[56] Perioral dermatitis with histopathologic features of granulomatous rosacea: successful treatment with isotretinoin.
Cutis 1990 Nov; 46(5):413-5. Smith KW

[57] Face Up to Rosacea
Heather L. Roebuck MSN, RN, APRN, BC
The Nurse Practitioner: The American Journal of Primary Health Care September 2005; Volume 30 Number 9, Pages 24—35
http://www.nursingcenter.com/prodev/ce_article.asp?tid=601568

[58] PERIORAL DERMATITIS: AETIOLOGY AND TREATMENT WITH TETRACYCLINE British Journal of Dermatology 87 (4), 315–319. doi:10.1111/j.1365-2133.1972.tb07416.x; ANGUS MACDONALD, MICHAEL FEIWEL (1972)
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-2133.1972.tb07416.x?journalCode=bjd

[59] Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea Journal of the American Academy of Dermatology April 2002 • Volume 46 • Number 4
http://www.rosacea.org/rr/2002/summer/article_1.html

[60] Old drug—in a new system—revisited.
Olansky S; Cutis. 1977 Jun;19(6):852-4.

[61] Recognizing rosacea
Could you be misdiagnosing this common skin disorder?
Millikan L.,
Postgrad Med 1999;105:149–58.

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