Perioral dermatitis: clinical guidelines

List of Abbreviations

ICD – International Classification of Diseases

PODSI — Perioral Dermatitis Severity Index

Terms and Definitions

Perioral dermatitis (syn.: rosacea-like dermatitis, photosensitive dermatitis, steroid-induced dermatitis, photosensitive seboroid) is a chronic, relapsing facial skin disease manifested by erythematous-papular, papulovesicular, and less commonly papulopustular eruptions predominantly in the perioral region.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Perioral dermatitis (syn.: rosacea-like dermatitis, photosensitive dermatitis, steroid-induced dermatitis, photosensitive seboroid) is a chronic, relapsing facial skin disease manifested by erythematous-papular, papulovesicular, and less commonly papulopustular eruptions predominantly in the perioral region [1, 2, 44].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The development of perioral dermatitis is promoted by the following factors:

- Prolonged use of corticosteroids (topically or systemically) and medications containing them [2, 5-7];

- Mites of the genus Demodex [8, 9];

- Infectious agents: yeast-like fungi of the genus Candida [6], obligate anaerobic bacteria [2, 10, 11];

- Use of cosmetic products (moisturizers, cleansers, sunscreens) having an occlusive effect [12–14];

- Use of fluoride-containing toothpastes [15–18];

- Ultraviolet radiation [2, 19].

Background conditions for the development of perioral dermatitis may include: use of contraceptive medications, pregnancy, impaired skin barrier function, including in patients with atopic dermatitis using topical corticosteroids [8, 15, 20, 21].

1.3 Epidemiology of the Disease or Condition

The prevalence of perioral dermatitis in the population is 0.5–1%, predominantly affecting women aged 15–45 years. Perioral dermatitis can occur in childhood, with the peak incidence in puberty, and the disease is more frequently observed in boys [3]. About 2% of patients visiting a dermatologist suffer from perioral dermatitis. Fair-skinned individuals are affected more often [4].

1.4 Features of Coding the Disease or Condition

Code according to the International Classification of Diseases ICD-10 —

L71.0 Perioral dermatitis

1.5 Classification of the disease or condition

There is no universally accepted classification of perioral dermatitis.

1.6 Clinical presentation of the disease or condition

Depending on the severity of clinical manifestations, mild, moderate, and severe forms of perioral dermatitis are distinguished. Severe perioral dermatitis includes granulomatous perioral dermatitis [22, 44].

To determine the severity of perioral dermatitis, the PODSI index has been developed, which is based on assessing the severity of clinical manifestations such as erythema, papules, and desquamation (Appendix G1).

The disease is characterized by clearly demarcated erythema of varying severity, as well as dome-shaped, non-follicular, pinkish-red papules, papulovesicles, less commonly papulopustules, 1–2 mm in diameter, which are localized in the perioral and periorbital areas, nasolabial folds, and may also spread to the skin of the chin and cheeks. A characteristic feature of perioral dermatitis is a narrow rim of pale, lesion-free skin around the vermilion border of the lips [22].

In the granulomatous form of perioral dermatitis, reddish-brown, less commonly skin-colored papules are observed, which may be localized not only in typical areas for the disease, but also on the skin of the neck, trunk, and extremities. Diascopy reveals a positive "apple jelly" sign [24].

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnosis of perioral dermatitis is based on an examination by a dermatovenereologist, analysis of medical history, and clinical presentation. History data and typical clinical presentation are used as diagnostic criteria.

2.1 Complaints and Anamnesis

Typical complaints of patients with perioral dermatitis include a sensation of burning, soreness, as well as tightness and tension of the skin in the affected area. Itching may occur, but is not characteristic [25, 57].

2.2 Physical Examination

Objective clinical manifestations of perioral dermatitis detected during physical examination are described in the "Clinical Presentation" section.

2.3 Laboratory Diagnostics

Additional laboratory tests are not indicated for the diagnosis of perioral dermatitis.

2.4 Instrumental Diagnostics

Not applicable.

2.5 Other Procedures

Not applicable.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

The choice of drug and treatment method for perioral dermatitis depends on the severity and stage of the disease. For the duration of treatment, regardless of the chosen therapy method, the use of cleansing and moisturizing cosmetics, decorative cosmetics, fluorinated toothpastes, as well as topical and systemic drugs containing corticosteroids or D07 Corticosteroids, dermatological preparations, is discontinued (when discontinuing systemic preparations containing systemic corticosteroids, it is necessary to consider the indications for which the drugs were prescribed, and the patient should be advised to consult the prescribing physician regarding the possible discontinuation of the drug) [1, 11, 14, 27, 28].

3.1 Conservative Treatment

"Zero" therapy (or zero-therapy), topical therapy, and systemic therapy for perioral dermatitis are used.

"Zero" therapy

Comments: If "zero" therapy is ineffective, drug therapy is prescribed. Topical therapy is prescribed for mild and moderate severity of the disease, used as monotherapy, and in severe perioral dermatitis can be prescribed in combination with systemic therapy (see Appendix B).

Topical therapy

#metronidazole 0.75-1% gel, cream, topically twice daily for 8 weeks [32, 50, 51].

GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5)

or

#azelaic acid 20% cream, topically twice daily for 2–6 weeks [33, 34].

GCR CLEL 4Grade of Recommendation — C (Level of Evidence — 4)

or

#pimecrolimus** 1% cream, topically twice daily for 4 weeks [18, 23, 35, 52].

GCR BLEL 2Grade of Recommendation — B (Level of Evidence — 2)

Systemic therapy is prescribed for severe forms of the disease, as well as when topical therapy is ineffective.

#tetracycline 250–500 mg orally twice daily for 4–8 weeks [29, 32, 33, 36, 37, 52, 53, 54, 55, 56].

GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5)

Comment: Prescribed to patients over 8 years of age.

or

#doxycycline** 100-200 mg daily orally for 4-8 weeks [37, 45, 46].

GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5)

Comment: Prescribed to patients over 8 years of age.

#erythromycin 250 mg orally twice daily for 1 to 3–4 months [38–40, 54].

GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5)

Management in the absence of treatment response

3.2. Surgical treatment

Not applicable.

3.3. Other treatment

Diet therapy is not indicated.

Pain management is not performed.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not performed.

5. Prevention and Dispensary Observation

Prevention of disease development consists of the following:

- restriction of the use of corticosteroid-containing preparations;

- restriction of the use of cosmetics.

Dispensary observation (follow-up) is not performed.

6. Organization of Medical Care

There are no indications for hospitalization in a medical organization.

Medical care is provided within the framework of primary specialized health care by dermatovenereologists in an outpatient setting.

7. Additional Information

Information is not available.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Kubanov Alexey Alekseevich — Academician of the Russian Academy of Sciences, President of the Association "Russian Society of Dermatovenereologists and Cosmetologists", Director of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health, Moscow.

2. Araviyskaya Elena Alexandrovna — Doctor of Medical Sciences, Professor of the Department of Dermatovenereology with Clinic at the First St. Petersburg State Medical University named after Academician I.P. Pavlov of the Russian Ministry of Health, Member of the Russian Society of Dermatovenereologists and Cosmetologists, St. Petersburg.

3. Monakhov Konstantin Nikolaevich – Doctor of Medical Sciences, Professor at the Department of Dermatovenereology with Clinic, Pavlov First Saint Petersburg State Medical University of the Ministry of Health of Russia, member of the Russian Society of Dermatovenereologists and Cosmetologists, St. Petersburg.

4. Chikin Vadim Viktorovich – Doctor of Medical Sciences, Senior Researcher at the Department of Dermatology, State Research Center of Dermatovenereology and Cosmetology of the Ministry of Health of Russia, member of the Russian Society of Dermatovenereologists and Cosmetologists, Moscow.

5. Vorontsova Anastasia Aleksandrovna – Junior Researcher at the Department of Dermatology, State Research Center of Dermatovenereology and Cosmetology of the Ministry of Health of Russia, member of the Russian Society of Dermatovenereologists and Cosmetologists, Moscow.

Conflict of Interest: The authors declare no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Medical specialists: dermatovenereologists, cosmetologists.

2. Residents and trainees of continuing professional education programs in the specified specialty.

Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The clinical guidelines update mechanism provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

• Procedure for the provision of medical care in the profile of «dermatovenereology», approved by Order of the Ministry of Health of the Russian Federation No. 924n dated November 15, 2012.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

1. Patients with perioral dermatitis are indicated for discontinuation of corticosteroids or D07 Corticosteroids used in dermatology and occlusive cosmetic products

2. Patients with perioral dermatitis are indicated for gentle skincare using specialized products

3. Patients are advised against natural ultraviolet irradiation, as well as visiting tanning salons. The use of a sunscreen product adapted for oily and problematic skin is recommended.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Patch skin test reaction scale

The PODSI index is designed to assess the severity of perioral dermatitis.

Original title: PeriOral Dermatitis Severity Index.

Source (official developer website, validation publication):

Wollenberg A, Oppel T. Scoring of skin lesions with the perioral dermatitis severity index (PODSI). Acta Derm Venereol. 2006;86(3):251-2.

Type (underline):

- assessment scale

- index

- questionnaire

- other (specify):

Purpose: assessment of the overall severity of perioral dermatitis

Content (template):

Calculation of the PODSI index

Key (interpretation): The PODSI index value is the sum of scores for the severity of erythema, papules, and desquamation, according to the presented eruption characteristic options for each severity degree, where «0» means «absence of the sign», 1, 2, 3 points – the severity degree of the sign, and intermediate degrees of 0.5; 1.5, and 2.5 may also be used.

Mild perioral dermatitis corresponds to PODSI index values of 0.5–2.5, moderate severity to 3.0–5.5, and severe form to 6.0–9.0 [18, 23].