Perioral dermatitis 

Dr. Wu's analysis
How do you recognize and perioral dermatitis?
How do you effectively treat perioral dermatitis?
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Dr. Wu's analysis

The name clown eczema (also known as dermatitis perioralis) already reveals it: this benign and non-contagious skin condition causes a red, irritated skin with small inflamed bumps (papules and pustules). Although they resemble pimples, this is a form of eczema, where the skin becomes sensitive and unbalanced. This rash mainly occurs around the mouth, but can also appear around the nose or eyes. Interestingly, the area directly around the lips usually remains free of rash. Dermatitis perioralis can persist if not treated, but with the right approach, the symptoms can disappear faster.

The exact cause of clown eczema is still not fully known. However, various factors have been identified that can play a role in the onset or worsening of the condition. Below are the 5 most well-known causes.

1. Use of corticosteroids
Corticosteroids on the face are one of the main triggering factors for clown eczema. The stronger the hormone, the greater the risk. Even mild variants, such as hydrocortisone acetate, can cause this condition. The exact cause is still unclear, but presumably corticosteroids disrupt the natural balance of microorganisms on the skin. A healthy skin barrier, in collaboration with harmless bacteria, protects against external influences. Corticosteroids can weaken this protection, making the skin more sensitive to irritation and inflammation.
2. Skincare products and cosmetics
Various cosmetic products can provoke or exacerbate clown eczema. This is particularly true for:
  • Creams and ointments with a sealing effect (occlusive), such as greasy skin care products.
  • Make-up and foundations with irritating ingredients.
  • Perfumed or strongly foaming cleansers.
  • Fluoride-containing toothpastes (such as 5000 ppm fluoride).
3. Environmental factors and habits
Clown eczema can also be influenced by external factors, such as:
  • Weather changes: Cold wind, dry weather, or high humidity can disrupt the skin barrier.
  • UV radiation: Exposure to the sun can irritate the skin and worsen symptoms.
  • Mechanical irritation: Frequently touching the face, excessive scrubbing, or intensive facial treatments.
  • Mouth contact with irritating substances: For example, frequently chewing gum or licking lips.
4. Hormonal influences
Hormonal fluctuations can play a role in the onset or worsening of clown eczema. This is often seen in women:
  • During the premenstrual period.
  • During pregnancy. When using hormonal contraception, such as the pill or the Mirena coil.
5. Medication
Certain medications can increase the risk of clown eczema, such as:
  • Inhaled corticosteroids (for example, in asthma).
  • Immunosuppressants that weaken the skin's defense.

What is NOT a cause?
Although clown eczema is often confused with bacterial skin infections, so far no bacterial pathogen has been identified through culture research. This means that antibiotics are not used because of an infection, but mainly to inhibit the inflammatory response.

Clown eczema can affect anyone, but some people are more susceptible to it. Gender, age, skin type, and environmental factors play a big role.

Gender
Women are more often affected than men, mainly due to hormonal fluctuations (menstruation, pregnancy, contraception) and more intensive use of skin products and makeup. Men are less susceptible, but can develop symptoms due to corticosteroids, irritating products, or regular skin irritation.
Age
Clown eczema mainly occurs in young adults between 16 and 45 years old. However, children between 7 months and 13 years can also develop symptoms, usually due to regular skin contact with saliva, certain creams, or cold weather conditions.
Skin type
People with a sensitive, dry, or atopic skin have a higher risk of clown eczema. Due to a vulnerable skin barrier, they react more quickly and intensely to triggers such as toothpastes, aggressive cleansers, or cosmetic products.
Environment
Exposure to sun, cold wind, dry air or frequent use of certain skin products can trigger or worsen clown eczema. A protective approach, such as daily sun protection and avoiding extreme weather conditions, helps to protect the skin.

How do you recognize and distinguish pigmentation spots?

Clown eczema has a recognizable pattern, these are the main characteristics:

– Small red bumps (papules and pustules), sometimes with a flaky skin.
– A red, irritated skin around the mouth, nose or eyes.
– A tight or burning sensation, especially when exposed to irritating substances such as soap, sunlight or water.
– No comedones (blackheads). Comedones, better known as blackheads, are clogged hair follicles that often occur with acne; these can be open (blackheads) or closed (whiteheads). The absence of blackheads is an important characteristic that distinguishes perioral dermatitis from acne.
– An episodic course, where the rash can worsen and then decrease.

An experienced dermatologist can often diagnose it by sight. If additional research is needed, a skin biopsy can be taken. This will show a mild, non-specific inflammatory response around blood vessels (perivascular) or hair follicles (perifollicular).

Clown eczema can easily be confused with other skin conditions that cause redness, bumps, or flaking. These are the 9 main conditions it can overlap with and the differences that can help you distinguish them.

Rosacea
  • Rosacea often occurs on the cheeks, nose, forehead and chin, while clown eczema is mainly found around the mouth and sometimes around the eyes.
  • With rosacea, the areas around the eyes and mouth usually remain free, while these are hotspots for clown eczema.
  • Both rosacea and clown eczema lack blackheads (comedones), which is a major distinction from acne.
  • A typical characteristic of rosacea is the presence of telangiectasias (small, dilated blood vessels), which does not occur with clown eczema.
Acne
  • An important difference is that acne contains comedones (blackheads), while these are absent in clown eczema.
  • Acne often occurs on the forehead, nose and chin (the T-zone), while clown eczema occurs around the mouth and eyes.
  • Acne is often influenced by sebum production and hormonal fluctuations, while clown eczema is more often triggered by irritating skin care products or corticosteroids.
    • Allergic contact dermatitis
    Contact eczema causes flaky spots, maculae and plaques, with the skin often thickening due to persistent irritation. This inflammatory reaction is directly triggered by skin contact with an allergen, and when the trigger is avoided, the symptoms usually disappear.
    Demodex folliculitis
    Demodex folliculitis is a skin inflammation condition caused by an excessive presence of Demodex mites. These mites, which normally live in the skin, can lead to irritation and inflammation when overgrown. This results in scattered, reddish papules (small raised bumps) and pustules (bumps with pus) on the face. Demodex mites also play a role in rosacea, another condition characterized by redness and inflammation.
    Irritating cheilitis (e.g. lip-licker's cheilitis)
    Lip lick dermatitis is caused by excessive licking of the lips, which leads to saliva breaking down the protective skin barrier. The saliva contains enzymes that, with repeated exposure, weaken and damage the skin, causing irritation and inflammation. This process results in redness and flaking of the lips, with the lip edge being particularly affected. For comparison, with clown eczema, the irritation is mainly around the mouth.
    Sarcoidosis
    This condition can cause reddish-brown papules in the areas around the natural openings of the face, such as the mouth, nose, and eyes - also known as the periorificial parts. In addition, the condition often occurs in a more extensive form and is accompanied by systemic symptoms, such as lung problems or enlarged lymph nodes. A skin biopsy can be performed to confirm the diagnosis.
    Seborrheic eczema
    Seborrheic eczema causes redness and greasy flakes, especially in the areas around the nasal fold, the eyebrows, and along the hairline. Unlike clown eczema, seborrheic eczema responds well to treatments with anti-fungal creams and special shampoos.
    Syringomen
    Small, skin-colored to light red bumps appear on the face, which sometimes resemble perioral dermatitis. These bumps usually feel smoother and firmer and change less quickly under the influence of external factors. In some cases, a skin biopsy may be useful to confirm the diagnosis.
    Tinea faciei (fungal infection on the face)
    Tinea facei is a fungal infection that manifests as red, flaky bumps and ring-shaped spots on the face. Although the symptoms in some ways resemble those of clown eczema, the edges in tinea facei are often more sharply defined and are accompanied by itching or burning. A fungal culture or the use of an antifungal cream can help confirm the diagnosis and start treatment.

    Although clown eczema is often considered a single condition, it can manifest in different forms. The variations are mainly determined by the location, severity, and underlying causes. Below are different forms, ranging from the most common to the rarest:

    Classic perioral dermatitis
    Classical clown eczema is the most common form of perioral dermatitis. It is characterized by red papules and pustules that manifest around the mouth, sometimes with slight scaling. Notably, the area directly around the lips usually remains free of rash. Often, this condition is caused by the use of corticosteroids, certain skin care products, or other irritating substances.
    Periocular dermatitis (periorbital dermatitis)
    Periocular dermatitis is a skin condition that primarily occurs around the eyes and on the eyelids. It is characterized by small, red bumps and redness, sometimes accompanied by itching or a pulling sensation. This condition is less common than perioral dermatitis, which occurs around the mouth. Both periocular and perioral dermatitis can be triggered by the use of topical corticosteroids or irritating cosmetics. Other possible factors include stress, hormonal changes, allergies, and certain medications.
    Perinasal dermatitis
    This form of dermatitis is primarily located around the nose and often involves the nostrils. The rash can be red, flaky, and with small bumps, and can sometimes resemble rosacea. However, unlike rosacea, telangiectasias, which are burst blood vessels visible under the skin, are usually absent. Perinasal clown eczema can be caused by various factors, including frequent nose rubbing, the use of irritating nasal sprays, or certain toothpastes that can irritate the skin around the nose.
    Generalized perioral dermatitis
    is a more extensive form of this skin condition where the rash is not only located around the mouth, but can also spread to the cheeks, chin and even the forehead. This form is often seen in people who use corticosteroids on the skin for a long time. The use of these medicines can lead to a worsening of the symptoms and the development of a more extensive rash. Other possible factors contributing to the development of generalized clown eczema are stress, hormonal changes, allergies, and certain cosmetics or cleaning products.
    Granulomatous perioral dermatitis
    is a rare form of this skin condition that mainly occurs in children and young adults. Instead of the typical red bumps, this variant causes yellow to reddish-brown bumps on the skin. This form can be more persistent and often responds less well to standard treatments. In rare cases, this condition can be accompanied by an inflammation of the eyelids (blepharitis) or the white of the eye (conjunctivitis), making a consultation with an ophthalmologist advisable. Other systemic complaints are usually not present.

    How do you effectively treat pigmentation spots?

    Clown eczema can be annoying and persistent. Fortunately, you can do a lot yourself to get your skin calm and healthy again.

    Step 1: Stop using irritating products.
    • Avoid products with alcohol, perfume, sulfates, silicones, and preservatives.
    • Use a fluoride-free toothpaste if fluoride is a trigger.
    • Stop using hormone ointments (corticosteroids), but taper off gradually.
    • Only use lukewarm water and a mild cleanser without foaming agents.
    Step 2: Supportive use of active ingredients
    • Calming ingredients: Ceramides, panthenol, niacinamide.
    • Hydration without sealing: Hyaluronic acid.
    • UV protection: Use a mineral sunscreen (zinc oxide, titanium dioxide).
    Step 3: Limit makeup and burdensome products.
    • Do not use closing foundations with silicone or oil.
    • Choose mineral makeup without irritating substances.
    • Avoid aggressive scrubs and chemical exfoliants.

    The treatment of clown eczema mainly focuses on actively reducing inflammation and addressing specific triggers. While care focuses on daily skin care and prevention, treatment goes a step further with targeted medical interventions. These treatments work most effectively under the guidance of a dermatologist, so your skin recovers faster and stays healthy for a long time.

    Local medication (creams and gels)
    Dermatologists often prescribe anti-inflammatory or antibiotic creams, such as metronidazole, erythromycin or clindamycin. Alternatively, calcineurin inhibitors such as tacrolimus (Protopic) or pimecrolimus (Elidel) can be used, which effectively reduce inflammation without side effects such as skin thinning.
    Systemic medication (tablets)
    For severe or prolonged complaints, oral medications are needed to tackle inflammation from within. Antibiotics such as doxycycline, minocycline or erythromycin are prescribed due to their anti-inflammatory properties. The treatment lasts on average 4-6 weeks.
    Light therapy
    Red LED light therapy can be a supplementary medical treatment. This therapy stimulates recovery processes in the skin, reduces inflammation, and promotes healing.
    Restoration of the skin microbiome
    Additionally, probiotics can be used to reduce inflammation at a systemic level. Specific strains such as Lactobacillus rhamnosus and Bifidobacterium lactis help restore the natural balance of the skin through the gut microbiome.

    For pigmentation spots, it is important to avoid certain habits and products, as these can worsen the spots or make the skin more sensitive. Try to avoid these 6 things as much as possible:

    1. Unprotected exposure to the sun
    UV radiation stimulates the production of melanin and can make existing pigmentation spots darker. Using a sunscreen with at least SPF30 daily is essential, even on cloudy days.
    2. Aggressive skin care products
    Avoid products with irritating substances such as alcohol, perfume, and strong foaming agents (such as sulfates). These can weaken the skin barrier and cause inflammation, which can trigger pigmentation.
    3. Self-bleaching creams without guidance
    Some over-the-counter creams contain harmful substances such as hydroquinone or corticosteroids, which can have harmful effects with prolonged use, such as thinning skin or even rebound hyperpigmentation. Only use pigment-reducing creams that have been dermatologically tested.
    4. Scrubbing and hard exfoliation
    Excessive scrubbing or aggressive chemical exfoliants can irritate the skin and worsen post-inflammatory hyperpigmentation, especially in dark skin. Instead, opt for gentle exfoliation with ingredients such as glycolic acid or lactic acid.
    5. Squeezing or scratching wounds and pimples.
    This can damage the skin and lead to post-inflammatory hyperpigmentation. Let wounds heal naturally and use soothing and restorative ingredients such as niacinamide or panthenol.
    6. Skin treatments without professional advice
    Not every laser or peel is suitable for every skin type. Incorrect treatments can worsen pigmentation spots, especially on tinted skin. Seek advice from a skin therapist or dermatologist before undergoing a treatment.

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    🛈 These products are cosmetic and intended for the care of healthy, sensitive or unbalanced skin. They are not intended as a medical treatment or to replace professional medical advice. For personalized skin advice, we recommend consulting a skin therapist or doctor.

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    Calming Cream, Langdurig Antibiotica Gebruik, Microbioom, Acne, Puisten
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    Tips when you have perioral dermatitis

    Tip 1: Use safe ingredients.
    • Sunscreen based on mineral sun filters (such as zinc oxide and titanium dioxide).
    • Mineral foundation that is non-comedogenic and light in structure.
    • Safflower oil with linoleic acid: an ingredient used in products for sensitive skin.
    • Pay attention to skin care that does not feel greasy, but contains ingredients such as niacinamide or vitamin C, which are mentioned in the literature for their skin care properties.
    Tip 2: Nutrition and lifestyle
    • Avoid foods that can aggravate inflammation, such as sugars, dairy, and heavily processed foods.
    • Maintain a diet rich in omega-3 fatty acids, antioxidants, and fiber.
    • Stress can play a role in skin inflammation. Regular relaxation, sleep, and exercise can contribute to skin recovery.
    Tip 3: Step-by-step plan for home treatment
    • Use as few products as possible and opt for mild formulations without perfume or alcohol.
    • Moisturizing ingredients such as ceramides and panthenol can help support the skin in case of dryness or sensitivity.
    • Protect your skin from UV radiation with a sunscreen with SPF 30 or higher.
    • Avoid irritating ingredients such as aggressive exfoliants or fragrances, especially with sensitive skin.

    Read our articles about perioral dermatitis here

    What you need to know about dermatitis perioralis, also known as clown’s eczema

    Common facial rash in women. Clown eczema or dermatitis perioralis is often mistaken for acne....
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