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Case Note

Case note: Papular eruption on the face

History

A 17-year-old healthy male high school student, with a past medical history of nodulocystic acne (with scarring) presents for management of acne scarring

Initial evaluation

  • No significant past medical history
  • Presents for management of 3 weeks' history of a papular eruption on the face
  • Recent history of several insect bites on the face, for which he used topical triamcinolone 0.1% ointment (prescribed earlier for poison oak dermatitis on the leg) approximately 1 month ago
  • Denies use of inhaled steroids or other cosmetics on the face
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Enter your diagnosis

Diagnosis

  • A diagnosis of periorificial dermatitis is rendered

Initial Treatment

  • Recommendations:
    • Doxycycline 100 mg twice-daily for 21 days and application of metronidazole 1% cream twice-daily
    • Cease using topical steroid on face
  • Follow-up in 3 weeks

Follow-up evaluation strategy

3-week follow-up evaluation:

  • Much improved
  • Oral doxycycline is discontinued, however, the metronidazole cream is continued for several additional weeks
  • Follow-up in 4 weeks (rash is resolved)

Further recommendations:

  • Doxycycline or minocycline 100 mg once-daily may be used to ease compliance in patients intolerant of, but not allergic to, oral tetracycline
  • In tetracycline-allergic patients whose lesions do not clear with topical therapy, oral erythromycin or a second generation cephalosporin can be attempted, although this is rarely required

General discussion

Periorificial dermatitis is a common eruption of the face and is marked by erythematous papules, pustules, or papulovesicles (without comedones), sometimes with scale or eczematous appearance. It typically affects the periocular, perinasal, and perioral areas, with the perioral area being most commonly affected. When it affects the perioral region, a rim of normal skin usually separates the lips from the affected skin of the chin and cheeks. Patients often report a burning sensation in association with this rash.

This form of dermatitis is frequently related to the use of moderate-to-potent fluorinated topical steroids on the face. Other potential triggers of this condition include inhaled steroids (such as intranasal steroid sprays for allergic rhinitis or bronchial steroid inhalers for asthma), topical tacrolimus, fluorinated toothpaste, and facial cosmetics. In some cases, no triggering factors are found. Although it is considered by some to be related to rosacea, patients usually do not have flushing and other stigmata of rosacea. This condition affects young adult women most commonly.

As far as treatment is concerned, it is generally recommended that the first step is to identify and stop any offending agents still in use. Several therapeutic strategies, including oral antibiotics, topical medications, or both, can be used to reduce inflammation as outlined above - for example, in order to avoid the adverse effects of antibiotics on skin flora, a low, subantimicrobial dose of doxycycline (Oracea) could be used, that still has anti-inflammatory effects. Use of gentle skin care is an important adjunct with this strategy.

Treatment pitfalls to remain vigilant of with this approach include:

  • Yeast vaginitis: A common complication of oral tetracycline therapy
  • Tetracyclines: These are contraindicated in pregnancy and in children under the age of 8 years of age
  • Refractory perioral dermatitis: This may be caused through surreptitious or intermittent use of topical steroids by the patient. Since perioral dermatitis may be induced by even low-strength topical steroids (and there are case reports of perioral dermatitis caused by topical tacrolimus), avoidance of all topical steroids is preferred to 'weaning the patient off' by giving lower and lower strengths
  • Recurrent periorificial dermatitis may require the use of systemic isotretinoin (typically low-dose) as a therapeutic strategy
  • Misdiagnosis: Perioral dermatitis is typically a very responsive disorder so if lesions do not clear with the therapies outlined above, the diagnosis should be reconsidered. Other important diagnostic considerations include seborrheic dermatitis, rosacea, an irritant dermatitis, lupus miliaris disseminatus faciei, demodex folliculitis, or unusual drug eruptions

 

Further reading

Chen A, Zirwas M. Steroid-induced rosacealike dermatitis: case report and review of the literature. Cutis 2009;83: 198-204.

Jansen T, Melnik BC, Schadendorf D. Steroid-induced periorificial dermatitis in children-clinical features and response to azelaic acid. Ped Derm 2010;27:137-142.

Lipozencic J, Ljubojevic S. Perioral dermatitis. Clin Dermatol 2011;29:157-161.

Poulos G, Brodell R. Perioral dermatitis associated with an inhaled corticosteroid. Arch Derm  2007;143:1460.

Nedorost S. Medical Pearl: the evaluation of perioral dermatitis: use of an extended patch test series. J Am Acad Dermatol 2007;56:S100-102.

Schwarz T, Kreiselmaier I, Bieber T,et al. A randomized, double-blind, vehicle-controlled study of 1% pimecrolimus cream in adult patients with perioral dermatitis. J Am Acad Dermatol 2008;59:34-40.

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