Perioral dermatitis

The name Dutch name for perioral dermatitis is clowns eczema and says it all. It is a benign and non-contagious skin condition and can be recognized by the small inflammatory papules and pustules and/or red/pink scaly fields. The bumps are not real pimples, they are eczema bumps, filled with fluid.

In this condition, the area around the mouth (periorale) or around the eyes (periocularis) is affected. It is striking that the area immediately around the lip red is not affected. However, the skin abnormalities can also occur on either side of the nose.

Sometimes the forehead, eyelids and between the eyebrows are also affected. The papules often develop in attacks and cause irritation such as itching and burning. The complaints can be aggravated by soap, sunlight, and even contact with water.

In most cases, the diagnosis is made with a trained eye. And if tissue research is done, also known as a biopsy (histological examination), mild non-specific inflammation will become visible. The inflammations are between perivascular (around the vessels) and peri-follicular (around the follicle).

The exact cause of perioral dermatitis is still unknown.

The use of corticosteroids in the face may be a trigger for the condition. The stronger the hormone works, the greater the chance of developing perioral dermatitis, but sometimes the weakest active hormone (hydrocortisone acetate) can also be the cause. More about how to properly apply a hormone ointment?

It is still uncertain how topical corticosteroids can lead to perioral dermatitis, but damage to the microorganisms in the hair follicles is thought to play a role. The skin contains harmless bacteria that, together with the skin, form a natural barrier. When the skin barrier is broken, intruders can enter the skin more quickly. Until now, a bacterial pathogen of clown dermatitis has never been cultivated.

In addition to corticosteroids, there is a very long list of possible causes. This list ranges from medication, cosmetics and dental fillings to weather changes and even chewing gum and toothpastes with a high fluoride content (Colgate duraphat 5000 plus/Colgate maximum cavity protection). So many things could be a possible cause.

Hormonal factors can also trigger perioral dermatitis in women during the premenstrual period, during pregnancy and when using oral contraception or the Mirena IUD.

What ingredients should I avoid and where can I find them?

• Parabens: these extend the shelf life of products, but are very damaging to the skin. Among other things, they inhibit the growth of fungi and bacteria, so that they can influence your own skin microbiome.
• Phenoxethanol, sodium hydroxymethylglycinate, benzyl alcohol: these are solvents and fragrances and are more likely to trigger allergies
• Sulfates: often found in shampoos because they have a strong cleansing effect. For the skin, it may be too aggressive.
• Propylene glycol and propanediol. Is in make-up, cosmetics and amazingly also in muffins and cake.
• Toluene: diluent often found in nail polish and nail polish remover.
• Fluoride: in toothpaste
• Isopropyl myristate: is often found in body lotions and is quite safe for the skin. People with perioral dermatitis should watch out for it, because this substance is too aggressive for them.
• Oxybenzone: A substance that causes allergies on the skin. Is often found in sunscreen.
• Petrolatum (vaseline) PEGS and paraffin: seal the skin by putting a layer on it. Can help improve the skin barrier and lock in moisture, but in people with perioral dermatitis, it can close pores too much.
• Perfume
• Alcohol
• Oil-based foundation.
• Beeswax
• Colophony (resin) in chewing gum

Of food, chewing gum is the only product that can cause perioral dermatitis.

This condition is most common in women between the ages of 16 and 45. But children between the ages of 7 months and 13 years of both sexes are also not spared. It rarely occurs in men . Perioral dermatitis can persist if left untreated. In most cases they eventually resolve, but this can take weeks to months. With proper treatment, symptoms and rashes are likely to clear up much faster.

Perioral dermatitis can be treated effectively and safely in most people under the guidance of a dermatologist. Because the cause of clown dermatitis can differ from person to person, it is important to first understand what the triggering factors are and then initiate targeted treatment.

Step 1: Stop using triggering products

The first step is to identify possible triggering factors. Corticosteroids or irritating cosmetic products are often the culprit. By stopping its use, the skin can relax. Please note that abruptly stopping corticosteroids can sometimes temporarily lead to a worsening of the symptoms (rebound effect). Stay patient as this usually improves on its own.

Step 2: Local treatment (topical therapy)

If stopping the triggering factor has insufficient effect, the dermatologist may prescribe local treatments:

• Antibiotic creams/gels:
  Creams containing metronidazole, clindamycin or erythromycin are often used because of their anti-inflammatory and antibacterial effect. These are suitable for mild to moderate cases of clown dermatitis.

• Calcineurin inhibitors:
  For people who do not want to use antibiotics for a long time, Protopic (tacrolimus) or Elidel (pimecrolimus) are good alternatives. These agents inhibit inflammation without thinning the skin, which is what corticosteroids do.
  Please note: a short-lasting burning sensation may occur during the first few applications, but this usually disappears after a few days.

Step 3: Oral treatment (systemic therapy)

In persistent or severe cases, a short course of oral antibiotics may be necessary. These are mainly prescribed for their anti-inflammatory effect:

• Doxycyclin or minocyclin: Commonly used options in adults and children over 8 years old.
• Erytromycin: This is a safer alternative for younger children and pregnant women.

In some situations, the dermatologist may recommend a combination of oral and local therapy for faster and longer lasting results.

Step 4: Supportive treatments and skin care

1. Hydration and skin care:
   It is important to moisturize the skin well every day with a light, non-irritating cream. Choose products that strengthen the skin barrier, such as creams with ceramides, avena sativa, marshmallow root, panthenol or hyaluronic acid. Avoid heavy, occlusive creams such as Vaseline and silicone-containing products, as these can clog the skin.

2. Red LED-mask:
   A red LED mask can help reduce inflammation and promote skin recovery. This type of light therapy stimulates cell renewal and supports the healing of the skin in a gentle way.

3. Sun protection:
   Sunlight can make clown dermatitis worse, so daily protection is essential. Use a mineral sunscreen with zinc oxide and titanium dioxide for broad UV protection. These ingredients are less irritating to the skin and provide effective protection against both UVA and UVB radiation.

4. Probiotics:
   Although not yet fully proven, some research suggests that taking oral probiotics may help restore the skin microbiome and reduce inflammation. This can be a useful addition to standard treatment.

Which probiotics may be effective?

The following probiotic strains are often associated with positive effects on skin problems, including eczema and possibly clown dermatitis:

1. 1. Lactobacillus rhamnosus GG (LGG)

      • Known for its anti-inflammatory properties and strengthening the gut-skin axis.

   2. Lactobacillus paracasei

      • Can help strengthen the skin barrier and reduce inflammatory reactions.

   3. Bifidobacterium lactis

      • Improves gut health and reduces systemic inflammation, which can indirectly benefit skin problems.

   4. Lactobacillus plantarum

      • Has antioxidant and anti-inflammatory properties, which can protect the skin against external stimuli.

Choose a probiotic supplement that contains at least some of the strains mentioned above, with a total amount of at least 10 billion CFUs per serving.

To see an effect on the skin, it is recommended to take probiotics daily for 6 to 12 weeks.

Acne vulgaris manifests itself as inflamed papules, pustules, cysts and comedones on the face, chest and back. Mechanical causes such as friction from a helmet strap can lead to flare-ups and the involvement may resemble perioral dermatitis. Acne in adult women is characterized by inflamed papules on the chin and jawline and resembles perioral dermatitis.

Allergic contact dermatitis presents with flaking macules, patches and plaques with possible coarsening of the skin.

Demodex folliculitis causes scattered erythematous papules and pustules on the face, associated with Demodex mites, which are also involved in rosacea.

Irritant cheilitis, such as lip licker cheilitis, leads to redness and flaking of the lips and usually affects the lip margin.

Rosacea is a condition that manifests mainly in the central part of the face, including the nose, with inflamed papules and pustules. Telangiectatic erythema with flushing is often associated. Perioral dermatitis is often considered a variant of rosacea due to similar responses to treatments. A distinctive feature is the absence of comedones, which are characteristic of acne.

Sarcoidosis can cause reddish-brown papules on periorific areas of the face. These lesions are usually more extensive, may occur elsewhere on the skin, and are often associated with systemic symptoms.

Seborrheic dermatitis causes erythematous patches of greasy scales on various parts of the face and chest.

Syringomas and other benign lesions may cause lesions that resemble perioral dermatitis, with flesh-colored to erythematous facial papules. A biopsy can help with the diagnosis.

Tinea faciei, fungal infection of the face, results in erythematous scaly papules and annular plaques.