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

In this blog we draw extra attention to a common skin condition called clown eczema.

Dermatitis perioralis is a rash most commonly seen in women between the ages of 16 and 45. But children between the ages of 7 months and 13 years are not spared either. The skin condition consists of small inflammatory papules and pimples and/or red/pink scaly areas around the mouth or eyes. The bumps are not real pimples, they are eczema bumps, filled with fluid.

what’s in a name

The name Dutch name for perioral dermatitis is clowns eczema and says it all. In this condition, only the area around the mouth (perioral) or around the eyes is affected. Exactly how this dermatitis arises is still unknown.

Topical use of facial corticosteroids may be a trigger for the condition. 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.

There are harmless bacteria on the skin that form a natural barrier together with the skin. When that skin barrier is broken, intruders can enter the skin more quickly. No bacterial causative agent of perioral dermatitis has ever been cultured.

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 in?

• • 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.
  • 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: toxic chemical that often 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
  • Fusobacteria, this study showed that Fusobacteria were found in 57 (81%) of 70 patients with perioralis dermatitis, and in 14 (5%) of 271 with other conditions.
  • Demodex skin mite. One study looked at the relationship between Demodex folliculorum and perioral dermatitis. Biopsies were taken from the skin on the chin of 82 patients with perioral dermatitis and 70 control subjects. Patients previously treated with topical steroids had significantly more Demodex folliculorum mites than patients who had not received prior treatment with topical steroids. The density of mites increased significantly as the duration of treatment with topical steroids increased.
  • Oil-based foundation.
  • Beeswax
  • Colophony (resin) in chewing gum

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

• Which ingredients can I safely use?

• Mineral-based sunscreen (zinc oxide and titanium dioxide).
• Mineral foundation.
• Products that are free of perfumes.
• Safflower oil with linoleic acid: It improves the barrier function of the skin.
• Use skin care products that are not greasy, but have a restorative and calming capacity. Products such as niacinamide and vitamin C.

How do I recognize dermatitis perioralis?

Scaling, pustules, papules are symptoms that you see more often. That does not mean that you have dermatitis perioralis anyway. How do you know for sure that you are dealing with dermatitis perioralis?

One of the related skin diseases is rosacea. Both rosacea and perioral dermatitis are characterized by erythematous papules, red raised bumps on the face. However, rosacea is more common on the cheeks, nose, forehead and chin. The regions around the eyes and mouth are often free of papules in rosacea, while those are the hot spots in perioral dermatitis.

There are no blackheads (comedones) in both rosacea and perioral dermatitis. What we do see with rosacea are telangiectasias (small dilated blood vessels). Despite being clinically similar, they differ in cause and prognosis.

Perioral dermatitis is confused not only with rosacea, but also with acne. Redness, papules and pustules are also symptoms that occur with acne. This sometimes makes diagnosis difficult. The preferred location and origin/belonging play an important role here. In addition, comedones are present in acne, which is not the case in perioral dermatitis. More on: recognize the different forms of acne.

If there are red pimples, spots or spots on the face, it can be caused by various diagnoses. This often includes acne, rosacea, perioral dermatitis (clown’s eczema) or eczema. Distinguishing between these diagnoses can be very difficult. More on different spots on the face, self-diagnosis

What conditions may resemble this?

These are the two most discussed differential diagnoses (DD), but also consider: contact eczema, lip-licking dermatitis, atopic eczema, lupus miliaris, malabsorption syndrome (zinc deficiency) and demodex folliculitis.

A closer look

When a piece of skin is placed under the microscope (histological examination), a mild non-specific inflammation becomes visible. The inflammations are between perivascular (around the vessels) and peri-follicular (around the follicle).

What can I do about it?

Perioral dermatitis can be effectively and safely treated by a skin specialist in the majority of patients.

The first step is to identify the cause. In the event that corticosteroids or other cosmetic products are the culprit, sometimes simply discontinuing their use is enough.

If that does not help, medication can be prescribed or local or oral antibiotics can be used. There is no single standard therapy. The situation and age of the patients is a leading factor.

Oral antibiotics such as doxycycline, minocycline or tetracycline are often used, but they are less suitable for patients under 8 years of age. Lubricating with metronidazole or clindamycin or erythromycin is a good alternative in that case. Sometimes a combination of oral and the topical therapy is used.

Also:

1. Diet modifications: Avoiding certain foods known for aggravating skin conditions, such as dairy products, spicy foods, caffeine, and foods high in artificial additives, can help reduce inflammation.

2. Stressmanagement: Stress can be a trigger for perioral dermatitis. Relaxation techniques such as meditation, yoga, deep breathing exercises and regular exercise can help reduce stress and improve skin condition. More about stress and skin

3. Improving skin care routine: Avoiding harsh cleansers, scrubs and cosmetics that can irritate the skin, and instead opting for gentle, non-comedogenic products that soothe and hydrate the skin.

Should you do an allergy test?

A study of 101,403 patients revealed that 4,779 people suffered from perioral dermatitis, with allergic contact dermatitis identified as a major cause.

Metals, fragrances and preservatives were common allergens. Nickel sulfate emerged as the major allergen in this and other studies examining patients with periorbital dermatitis. More about nickel allergy and mascara

Among ophthalmic preparations, preservatives were high on the list, with phenylmercuric acetate emerging as the most important allergen. Thimerosal was another common sensitizer and was found as an additive in eye or ear drops at concentrations of 0.001% to 0.004%, contact lens solutions, mascara and other cosmetics.

It is essential to consider patch testing in patients with periorbital dermatitis if contact allergy is suspected to identify and avoid the allergens.

More about dermatitis perioralis

Prognosis

The starting point is of course to stop using cosmetic products that cause perioral dermatitis. Perioral dermatitis often responds readily to therapy, but can be chronic and recurrent. The prognosis of perioral dermatitis is good. Avoiding all externalities often leads to improvement. The scar that remains after the treatment heals on its own, although it can sometimes take a long time.

Literature

Hafeez Z. H. (2003). Perioral dermatitis: an update. International journal of dermatology, 42(7), 514–517.

Lee, G. L., Zirwas, M. J. (2015). Granulomatous Rosacea and peririficial dermatitis. Dermatol Clin, 33, 447-455.

Peters, P., & Drummond, C. (2013). Perioral dermatitis from high fluoride dentifrice: a case report and review of literature. Australian Dental Journal, 58(3), 371–372.

Tempark, T., Shwayder, T. A. (2014). Perioral dermatitis: A review of the condition with special attention to treatment options.

Tolaymat, L., Hall, M. R. (2020). Perioral Dermatitis. In Statpearls. Statpearls publishing.

Satyawan I, Oranje AP, van Joost T. Perioral dermatitis in a child due to rosin in chewing gum. Contact Dermatitis. 1990 Mar;22(3):182-3.

Hafeez F, Maibach H. An overview of parabens and allergic contact dermatitis. Skin Therapy Lett. 2013;18(5):5-7.

While you are here

Wearing a mouth mask to prevent the coronavirus makes sense, but there is an unexpected additional skin condition: Mascne. Pimples caused by wearing a mouth mask for a long time. One of the reasons why we can get Mascne is because the skin causes much more friction than usual through the mouth mask. The chronic friction disrupts your skin barrier, the protective skin oils and fats are absorbed by the mask. In combination with a humid environment as a result of respiration, they provide an environment in which bacteria and yeasts can grow more. More about Maskne