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Red lesions on face

A 63-year-old woman presented to a family medicine skin clinic for evaluation of red lesions on her face. The lesions had appeared several months earlier under her nose, on her eyelids, and around her mouth. She reported mild itchiness in these areas, but more often noticed a burning sensation. In the past, her symptoms had been separately attributed to angular cheilitis and blepharitis. A previously prescribed course of clobetasol 0.05% cream had worsened the appearance of the lesions.

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Red lesions on face

These small (1-3 mm) grouped and solitary erythematous papules distributed around the mouth and nares were classic presentations of perioral dermatitis. Although perioral dermatitis typically affects the skin around the mouth, a newer term—periorificial dermatitis—is used because the eruption can, as seen in this patient, involve the skin around the mouth, nares, and/or eyes. Pustules also may occur. There also is a granulomatous form of periorificial dermatitis that occurs in children.

Periorificial dermatitis more closely resembles a rosacea-like eruption than a true dermatitis. Patients often report that the affected areas burn or sting, although occasionally they may be pruritic. Like rosacea, the pathogenesis of periorificial dermatitis is not completely understood. A major risk factor for the development of this condition is the use of topical corticosteroids—especially high-potency products—on the face. Therefore, the most important step in treating periorificial dermatitis is the discontinuation of topical corticosteroids (if they were being used).

In adults, oral tetracycline antibiotics are the drug of choice. As in rosacea, oral antibiotics are used not for their antimicrobial effect, but for their anti-inflammatory effect. For this reason, subantimicrobial dosing of doxycycline has become increasingly common. This reduces the likelihood of antibiotic-related adverse effects and bacterial resistance. In children or adults with a contraindication to tetracyclines, erythromycin is often used. Topical alternatives include erythromycin, metronidazole, and pimecrolimus.

In this case, the patient was advised to discontinue the topical corticosteroid and was started on subantimicrobial dosing of delayed-release doxycycline 40 mg. If the delayed-release form is not available, or is prohibitively expensive, doxycycline 20 mg bid may be used. This patient was told that it could take several weeks for the condition to improve, and that tapering the medication might help reduce recurrence, which is common.

Image courtesy of Daniel Stulberg, MD, FAAFP. Text courtesy of D. Alexander Phillips, MD, and Daniel Stulberg, MD, FAAFP Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

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