Perioral dermatitis is a common inflammatory facial rash that typically affects the skin around the mouth and chin. The initial stages of treatment can sometimes make the rash appear worse, causing concern for patients. Understanding the triggers and navigating the body’s reaction to their removal is key to successful treatment.
Understanding Perioral Dermatitis
Perioral dermatitis presents as small, red or pink bumps, sometimes accompanied by scaling, primarily localized around the mouth. These bumps, which may resemble acne or eczema, often spare the narrow border of skin directly adjacent to the lips, known as the vermilion border. The condition belongs to a broader category called periorificial dermatitis because it can also involve the areas around the eyes and nose.
The cause of perioral dermatitis is not fully understood, but several common triggers have been identified. Prolonged use of topical steroid creams, even mild hydrocortisone, is a primary trigger. Other factors include heavy facial moisturizers, occlusive cosmetics, and fluorinated toothpaste. Identifying and removing these irritants is the foundational first step in management.
The Initial Flare: Why It Gets Worse
The answer to whether perioral dermatitis gets worse before it gets better is often yes, a phenomenon called the “rebound effect.” This temporary worsening is most dramatic when the underlying cause is topical steroid use that is abruptly stopped. The skin becomes physiologically dependent on the steroid’s anti-inflammatory effect.
When the steroid is withdrawn, the suppressed inflammation surges back, making the rash look more red, bumpy, and widespread. This rebound flare typically lasts for one to three weeks. This inflammation is a sign that the body is reacting to the absence of the drug and beginning the healing process.
Some non-steroidal topical treatments can also contribute to temporary irritation. Medications like azelaic acid or initial applications of topical antibiotics may cause increased redness or a mild burning sensation. This irritation subsides as the skin adjusts and the anti-inflammatory effects begin to take hold. Patients must resist the urge to reapply the steroid, which would perpetuate the cycle of dependency.
Navigating the Treatment Process
The primary goal is to manage inflammation and eliminate the underlying cause, often involving “zero therapy” by discontinuing all facial cosmetics and irritants. For moderate to severe cases, healthcare providers prescribe oral antibiotics, such as doxycycline or minocycline. These medications are used for their potent anti-inflammatory effects, not just their antibacterial properties.
Topical agents are often used with oral medication or alone for milder cases. Common topical treatments include metronidazole, erythromycin, or azelaic acid. Non-steroidal calcineurin inhibitors, such as pimecrolimus or tacrolimus, may be used as an alternative or to help wean off topical steroids.
Significant improvement begins after the initial flare subsides, requiring patience and consistency. A noticeable reduction in the rash may take four to eight weeks, though redness sometimes lingers longer than the bumps. The full course of treatment, including oral and topical regimens, can last for a minimum of three months.
Maintaining Clear Skin
Once the acute phase has resolved, the focus shifts to long-term prevention to avoid recurrence. The most important preventive measure is the permanent avoidance of all topical steroid products on the face. The skin remains sensitive to this trigger, and reintroduction can lead to a quick relapse.
Simplifying the daily skincare routine is an effective strategy for maintaining clear skin. This involves using only gentle, fragrance-free cleansers and minimizing heavy or occlusive moisturizers and makeup. Patients are often advised to switch to a fluoride-free toothpaste, as fluoride compounds can act as an irritant. Maintaining a healthy skin barrier is crucial for preventing future flare-ups.