Perioral dermatitis is a common and frustrating skin condition that is often treatment resistant and recurs when treatment stops. Perioral dermatitis is classified in the rosacea family of skin diseases, and it is often associated with fair skin, light eyes, and marked actinic damage.
Although it is common in white skin, perioral dermatitis is underdiagnosed and an increasing problem in skin of color as well. The condition often begins as a papular, erythematous rash around the mouth. In darker skin types, however, it is often misdiagnosed because the erythema is masked by the skin pigmentation, so it appears as reddish-brown or even hyperpigmented papules around the mouth or eyes.
Popular treatments for perioral dermatitis include oral doxycycline, topical metronidazole, and topical tacrolimus. Often patients self-treat with topical corticosteroids for quick relief, which can initially improve the condition. However, corticosteroid use can result in exacerbation of the disease once the steroid is stopped, and often leads to recalcitrant cases. In skin of color patients, topical steroids used around the mouth and eyes also cause hypopigmentation of the skin, which further masks the clinical presentation of the disease and contributes to underdiagnosis and improper management.
In my practice, I have seen a consistent link between perioral dermatitis in skin of color patients and diet. Often patients who develop the rash have gluten sensitivity or mild, undiagnosed gluten intolerance. When these patients are switched to a gluten-free diet, their skin condition improves. Similarly, patients with no clinically diagnosed gluten sensitivity but who adopt a carbohydrate-free/low-glycemic-index and high-protein diet have shown dramatic improvement with minimal oral or topical treatments and less recurrence.
Although there are no well-controlled studies – or even case reports – linking carbohydrate or gluten intake to perioral dermatitis, studies have shown a strong link between diet and rosacea. Erythematotelangiectatic and papulopustular rosacea are known to be exacerbated by alcohol, hot or spicy foods, and chocolate. However, the common ingredient in these foods has never been identified as a link to the exacerbation of the disease. As all of the aforementioned foods often contain carbohydrates, could the common link simply be carbs or processed sugar?
Carbohydrates are the most common nutrients in the American diet. Often, emigrants to the United States develop perioral dermatitis or other inflammatory skin conditions such as acne and rosacea that they did not have in their home countries. Perhaps the Paleo or Mediterranean diets that have become popular for weight loss help control both bowel and skin inflammation. More studies are needed to better define the complex relationship and causality between diet and perioral dermatitis. In the meantime, I have been recommending carb-free diets in addition to topical tacrolimus or metronidazole for my skin of color patients with perioral dermatitis to prevent recurrences, and I have seen excellent results.
Dr. Talakoub is in private practice in McLean, Va.
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