Perioral dermatitis: a review of the condition with special attention to treatment options

Characteristics of Rosacea and Similar Diseases in Patients Wearing Face Masks

Introduction

The present study aimed to obtain fundamental data, including climate conditions and Demodex mites, on rosacea and similar diseases in the situation where the wearing of face masks is mandatory due to the coronavirus disease 2019 pandemic.

Methods

We enrolled 86 Japanese patients habitually wearing face masks with rosacea and similar diseases. Disease severity was assessed using the Investigator Global Assessment. The presence of Demodex mites was examined microscopically. Treatment involved acaricidal and antibiotic agents.

Results

The numbers of male and female patients enrolled were 11 and 75, respectively. Among these patients, 85 (98.8%), 57 (66.3%), and 76 (88.4%) had rosacea, rosacea-like dermatitis (RLD), and demodicosis, respectively. The monthly number of patients with rosacea and demodicosis showed two peaks from May to June and in October, during which monthly mean temperature was approximately 20°C (68°F). Improvement rates in rosacea, RLD, and demodicosis were significantly higher when Demodex mites were no longer detected after treatment.

Conclusion

The present results suggest that a season with a mean temperature of approximately 20°C is a risk factor for rosacea and similar diseases in individuals wearing face masks in Japan, and a decrease in Demodex mites is associated with the attenuation of symptoms.

The impact of clinical nutrition on inflammatory skin diseases

The influence of nutrition on the pathophysiology and clinical severity of inflammatory facial dermatoses such as acne, rosacea, seborrheic dermatitis, and perioral dermatitis has been controversially discussed for years. As part of a modern treatment approach, clinicians should provide patients with information on how their choice of diet might impact their dermatologic diagnosis and could potentially enhance therapeutic outcome. Recently, the concept of a gut-skin axis has gained momentum in the understanding of inflammatory dermatoses, with nutrition considered a contributing factor in this context. For example, gastrointestinal symptoms in rosacea patients may indicate a dysbiosis of the gut microbiome, treatment of which may also improve severity of the skin disease. New research efforts were recently made for acne patients addressing the clinical effects of omega-3 fatty acids and probiotics. In contrast, due to the limited data available, no comparable specific dietary recommendations can yet be made for seborrheic or perioral dermatitis. However, there are promising signs that clinical nutrition and dermatology will be more extensively interlinked in the future, both clinically and scientifically.

Pharmacological interventions for periorificial (perioral) dermatitis in children and adults: a systematic review

The plethora of pharmacologic treatments used for periorificial dermatitis (POD) makes clinical decision-making challenging. The objectives of this review were to assess the efficacy and safety of pharmacological interventions for POD in children and adults. The search was performed on 2 February 2021 and included seven databases and trial registries, with no date or language restrictions Study selection, data extraction and risk of bias assessments were performed independently and in duplicate by two authors, in accordance with a prespecified protocol. Meta-analyses were performed and reported in accordance with PRISMA guidelines. Where meta-analysis was not possible, a narrative synthesis was performed and reported in accordance with SWiM guidelines. The certainty of evidence was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach. Eleven studies representing 733 participants were included. Oral tetracycline may improve physician-reported severity of POD from day 20 onwards (low certainty evidence). Adverse effects may include abdominal discomfort, facial dryness and pruritus. Pimecrolimus cream may improve physician-reported severity slightly after 4 weeks of treatment (MD -0.49, 95% CI -1.02 to 0.04, n = 164, low certainty evidence). Adverse effects may include erythema, herpes simplex virus infection, burning and pruritus. Azelaic acid gel may result in no change in either physician- or patient-reported severity after 6 weeks of treatment. The evidence is very uncertain about the effect of praziquantel ointment on physician-reported severity and skin-related quality of life after 4 weeks of treatment. The evidence is also very uncertain about the effect of topical clindamycin/benzoyl peroxide on physician-reported severity. The body of evidence to inform treatment of POD currently consists of low and very low certainty evidence for important outcomes. Well-designed trials are needed to further investigate treatment options. Data are required for children and from low-middle income countries to improve external validity. Future trials should also include adequate post-treatment follow-up and standardized outcome measures.

Unusual Spurts of Rosacea Like Dermatoses, Posing a Diagnostic Dilemma During Covid-19 Pandemic: A Cross-Sectional, Observational Study From a Tertiary Care Centre

Background:

The gradual opening of healthcare system since second week of May 2020 following lockdown imposed due to corona virus pandemic saw spurts of cases of unexplained central facial dermatoses in subset of previously healthy people. The aim of the study was to find out the cause and establish the definitive diagnosis of unusual occurrence of facial dermatoses on previously healthy people so that an appropriate management can be offered to the patients.

Materials and Methods:

It was a cross-sectional, observational study carried during May 15 to July 15, 2020 at a tertiary dermatology center. All cases presented with erythema on face and papular or pustular lesions on central facial area of not more than 2 months of duration were included in the study.

Results:

Total 81 patients visited skin OPD with facial dermatoses of various types during this period, out of which 21 patients fulfilled the inclusion criteria. This was 0.72% (21/2900) of total skin OPD of the 2 months. All the patients had been using face masks during this period of symptoms due to the ongoing coronavirus situation. Dermatological examination revealed only erythema on the central area of face (n = 10), erythema and few papules (n = 3), erythmatous papules and pustules (n = 5), and erythematous papules, pustules, and telengiectasia (n = 3). All the skin biopsies showed predominantly epithelioid cells, noncaseating granuloma with a variable degree of infiltrate.

Conclusion:

There has been a definite change in the lifestyle due to the current Covid-19 pandemic. People are compulsorily using face masks to avoid the spread of Covid-19 infection. This change in behavior has brought out a surge of rosacea like lesions on the covered area of face. Partly, it can be explained by change in innate immunity due to excessive sweating and change in microenvironment of skin.

Features of the Skin Microbiota in Common Inflammatory Skin Diseases

Many relatively common chronic inflammatory skin diseases manifest on the face (seborrheic dermatitis, rosacea, acne, perioral/periorificial dermatitis, periocular dermatitis, etc.), thereby significantly impairing patient appearance and quality of life. Given the yet unexplained pathogenesis and numerous factors involved, these diseases often present therapeutic challenges. The term “microbiome” comprises the totality of microorganisms (microbiota), their genomes, and environmental factors in a particular environment. Changes in human skin microbiota composition and/or functionality are believed to trigger immune dysregulation, and consequently an inflammatory response, thereby playing a potentially significant role in the clinical manifestations and treatment of these diseases. Although cultivation methods have traditionally been used in studies of bacterial microbiome species, a large number of bacterial strains cannot be grown in the laboratory. Since standard culture-dependent methods detect fewer than 1% of all bacterial species, a metagenomic approach could be used to detect bacteria that cannot be cultivated. The skin microbiome exhibits spatial distribution associated with the microenvironment (sebaceous, moist, and dry areas). However, although disturbance of the skin microbiome can lead to a number of pathological conditions and diseases, it is still not clear whether skin diseases result from change in the microbiome or cause such a change. Thus far, the skin microbiome has been studied in atopic dermatitis, seborrheic dermatitis, psoriasis, acne, and rosacea. Studies on the possible association between changes in the microbiome and their association with skin diseases have improved the understanding of disease development, diagnostics, and therapeutics. The identification of the bacterial markers associated with particular inflammatory skin diseases would significantly accelerate the diagnostics and reduce treatment costs. Microbiota research and determination could facilitate the identification of potential causes of skin diseases that cannot be detected by simpler methods, thereby contributing to the design and development of more effective therapies.

Topical Steroid-Induced Perioral Dermatitis (TOP STRIPED): Case Report of a Man Who Developed Topical Steroid-Induced Rosacea-Like Dermatitis (TOP SIDE RED)

The long-term use of topical corticosteroids can result in rosacea-like dermatitis or facial perioral dermatitis. The case of a 54-year-old man is described who developed topical corticosteroid-induced perioral dermatitis (TOP STRIPED), and the features of topical corticosteroid-induced rosacea-like dermatitis are reviewed. The man presented with a painful erythematous facial eruption. Additional history revealed that he had been applying a high-potency topical corticosteroid twice daily to the affected area. Correlation of the clinical history and cutaneous examination established a diagnosis of topical corticosteroid-induced rosacea-like dermatitis (TOP SIDE RED). Treatment of the patient’s TOP SIDE RED included not only discontinuing the high-potency corticosteroid but also initiating topical and oral antibiotics. In addition, a low-potency topical corticosteroid and metronidazole gel were also applied to the affected area. His facial rash resolved within three months and has not recurred. TOP STRIPED, also referred to as TOP SIDE RED, is an adverse side effect associated with the use of high-potency topical corticosteroids to the face. Management includes discontinuing the corticosteroid. Additional treatment may include a low-potency topical corticosteroid, antibiotics (systemic or topical or both), and/or topical calcineurin inhibitors, such as tacrolimus or pimecrolimus.

Perioral dermatitis: diagnosis, proposed etiologies and management

Perioral dermatitis is a common cutaneous condition characterized by acneiform facial eruptions often with an eczematous appearance. A granulomatous subtype exists in addition to the classic variant. Whilst topical corticosteroids have been largely implicated in this condition, its etiology is not completely understood. Using the keywords "corticosteroids," "dermatology," "fusobacteria," "perioral dermatitis", and "periorificial dermatitis" we searched the databases PubMed, MEDLINE and EMBASE to find the relevant literature. Only articles in English were chosen. The level of evidence was evaluated and selected according to the highest level working our way downwards using the Oxford Centre of Evidence-Based Medicine 2011 guidance. This systematic review found the strongest evidence to support topical corticosteroid misuse as the principal causative factor in the pathogenesis of perioral dermatitis. In terms of treatment, further research is required to robustly investigate promising treatment options including tetracyclines, topical metronidazole, topical azelaic acid, adapalene gel and oral isotretinoin.

Oral manifestations of inflammatory bowel disease: the neglected piece of the puzzle

Inflammatory bowel disease (IBD) is a chronic relapsing remitting autoimmune disease including Crohn's disease and ulcerative colitis. IBD is associated with various extra-intestinal manifestations including oral manifestation. To date, only limited studies addressing the characteristics of the oral manifestations are available. The aim of the present review is to report the oral manifestations and their characteristics in IBD. A Medline/PubMed and Embase databases search were conducted and all relevant studies were extracted and analyzed. Overall, the oral manifestations in IBD were mostly associated with Crohn's disease rather than Ulcerative colitis where their prevalence ranged from 8 to 50%. Specific lesions for Crohn's disease include mucosal tags, cobblestoning and deep linear ulcerations with vertical fissures, while for ulcerative colitis, pyostomatisis vegetans was more disease specific. Notably, most of the oral manifestations were unrelated to disease activity, however more data are needed to accurately assess this correlation. Oral manifestations among IBD patients are not uncommon as Crohn's disease account for most of them. More data are warranted to precisely characterize their prevalence and association to intestinal activity.

Acne in the first three decades of life: An update of a disorder with profound implications for all decades of life

Acne vulgaris is a chronic, inflammatory, skin condition that involves the pilosebaceous follicles and is influenced by a variety of factors including genetics, androgen-stimulation of sebaceous glands with abnormal keratinization, colonization with Cutibacterium acnes (previously called Propionibacterium acnes), and pathological immune response to inflammation. Acne can occur at all ages and this discussion focuses on the first three decades of life. Conditions that are part of the differential diagnosis and/or are co-morbid with acne vulgaris are also considered. Acne in the first year of life includes neonatal acne (acne neonatorum) that presents in the first four weeks of life and infantile acne that usually presents between 3 and 6 months of the first year of life with a range of 3 to 16 months after birth. Acne rosacea is a chronic, inflammatory, skin condition that is distinct from acne vulgaris, typically presents in adults, and has four main types: erythemato-telangiectatic, papulopustular, phymatous and ocular. Treatment options for acne vulgaris include topical retinoids, topical benzoyl peroxide, antibiotics (topical, oral), oral contraceptive pills, isotretinoin, and others. Management must consider the increasing impact of antibiotic resistance in the 21st century. Psychological impact of acne can be quite severe and treatment of acne includes awareness of the potential emotional toll this disease may bring to the person with acne as well as assiduous attention to known side effects of various anti-acne medications (topical and systemic). Efforts should be directed at preventing acne-caused scars and depigmentation on the skin as well as emotional scars within the person suffering from acne.

Tacrolimus ointment in the treatment of hormone-dependent dermatitis: A protocol of systematic review

BACKGROUND

Long-term use of corticosteroid ointment for external using or skin management products and cosmetics containing corticosteroid will produce a hormone-dependent effect on facial skin and destroy the barrier function of the skin. It is easy to cause repeated attacks of facial skin inflammation after drug withdrawal because corticosteroid hormones can cause the expression of inflammatory factors in the body, which has a serious impact on patients. The general treatment method is to stop using hormone drugs for psychotherapy and inform patients of the basic knowledge of hormone-dependent dermatitis and daily facial care, but the effect is not good. At present, non-steroidal ointment tacrolimus (a calcineurin inhibitor) is widely used in the treatment of hormone-dependent dermatitis. Tacrolimus ointment is effective for corticosteroid-dependent dermatitis, but adverse events can also occur.

METHODS

We plan to searched all randomized controlled trials (RCTs) fortacrolimus ointment therapy of hormone-dependent dermatitis in: MEDLINE, PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Springer and Web of Science, China Biomedical Literature Database (CBM), China Science Journal Database (VIP database) and Wanfang Database, China National Knowledge Infrastructure (CNKI), without the limitation of publication status and language until September 1, 2020. The systematic review will also search will also search for identify publications, meeting minutes, and grey literature (including unpublished meeting articles).

DISCUSSION

The systematic review mainly to access the safety and efficacy of tacrolimus ointment for hormone-dependent dermatitis (facial corticosteroid addiction dermatitis and facial steroid dermatitis). The results of our research will facilitate evidence-based management of patients with facial corticosteroid-dependent dermatitis and provide clinical advice on their treatment options.

REGISTRATION

PROSPERO CRD42020171813.

Predictive Model for Differential Diagnosis of Inflammatory Papular Dermatoses of the Face

Background

The clinical features of inflammatory papular dermatoses of the face are very similar. Their clinical manifestations have been described on the basis of a small number of case reports and are not specific.

Objective

This study aimed to use computer-aided image analysis (CAIA) to compare the clinical features and parameters of inflammatory papular dermatoses of the face and to develop a formalized diagnostic algorithm based on the significant findings.

Methods

The study included clinicopathologically confirmed inflammatory papular dermatoses of the face: 8 cases of eosinophilic pustular folliculitis (EPF), 13 of granulomatous periorificial dermatitis-lupus miliaris disseminatus faciei (GPD-LMDF) complex, 41 of granulomatous rosacea-papulopustular rosacea complex (GR-PPR) complex, and 4 of folliculitis. Clinical features were evaluated, and area density of papular lesions was quantitatively measured with CAIA. Based on these variables, we developed a predictive model for differential diagnosis using classification and regression tree analysis.

Results

The EPF group showed lesion asymmetry and annular clusters of papules in all cases. The GPD-LMDF complex group had significantly higher periocular density. The GR-PPR complex group showed a higher area density of unilateral cheek papules and the highest total area density. According to the predictive model, 3 variables were used for differential diagnosis of the 4 disease groups, and each group was diagnosed with a predicted probability of 67%~100%.

Conclusion

We statistically confirmed the distinct clinical features of inflammatory papular dermatoses of the face and proposed a diagnostic algorithm for clinical diagnosis.

Doxycycline, an Antibiotic or an Anti-Inflammatory Agent? The Most Common Uses in Dermatology

Doxycycline is a synthetic tetracycline that was approved in 1967. This wide-spectrum antibiotic has been shown to also have useful anti-inflammatory properties that make it suitable for the treatment of a number of noninfectious conditions. Tetracyclines are probably the most commonly prescribed antibiotics in dermatology, where they are usually used at doses lower than those effective against infections. They also have an excellent efficacy and safety profile. Because of doxycycline's ability to inhibit the molecular pathways associated with certain processes, this antibiotic can be used to treat hair follicle diseases, granulomatous diseases, and vascular proliferation, among other conditions. The main properties of doxycycline and its many applications in dermatology make this drug one that specialists should become familiar with.

Topical calcineurin inhibitors for pediatric periorificial dermatitis

BACKGROUND

Data regarding the treatment of periorificial dermatitis with topical calcineurin inhibitors (TCI) in the pediatric population are limited.

OBJECTIVE

To assess the clinical utility of TCI in pediatric patients with periorificial dermatitis.

METHODS

A retrospective medical record review of all pediatric patients with periorificial dermatitis treated with TCIs was performed. Follow-up via telephone was performed to capture missing data.

RESULTS

A total of 132 patients met the inclusion criteria. The median age at diagnosis was 4.2 years (interquartile range, 2.3-8.2). The median follow-up was 5.2 months (interquartile range, 2.1-11.7). Seventy-two patients had evaluable follow-up data. Of these, 48 (67%) patients were treated with TCI alone, 12 (16.7%) were treated with a combination of TCI and topical metronidazole, and 9 (12.5%) were treated with a combination of TCI and a systemic antibiotic. Complete response was noted in 68.8% of patients treated with TCI alone, in 75% of patients treated with TCI and metronidazole, and in 77.8% of patients treated with TCI and a systemic antibiotic. Adverse events were rare and mild in severity.

CONCLUSION

Topical calcineurin inhibitors are an effective therapeutic option for pediatric patients with periorificial dermatitis and were well tolerated in this cohort.

Recalcitrant granulomatous periorificial dermatitis with good response to low-dose oral isotretinoin

Granulomatous periorificial dermatitis is a clinical variant of periorificial dermatitis. We present the case of an 18-year-old girl with several reddish papular lesions in the perioral, perinasal, and periorbital regions unresponsive to conventional therapy. After 6 months of therapy with low-dose oral isotretinoin, the lesions fully remitted.

Subantimicrobial-dose doxycycline monohydrate in dermatology

Subantimicrobial doxycycline is an anti-inflammatory drug that decreases cathelicidin, kallikrein 5, reactive oxygen species, nitric oxide, and matrix metalloproteinases. Clinical trials demonstrated a comparable efficacy to 100-mg doxycycline in papulopustular rosacea with improvement of inflammatory lesions, quality of life, and improved safety profile. Case series and case reports suggested efficacy in other inflammatory skin diseases. The response of papulopustular rash during targeted anticancer therapies is mixed. Further studies are needed.

Morphology-Based Diagnosis of Acneiform Eruptions

Acne is the most common skin disease. Distinguishing between true acne vulgaris and the various acneiform eruptions is important yet sometimes challenging. Given the common nature of acne and acneiform eruptions, the pediatrician must be aware of these lesion patterns and possess the skills to effectively evaluate the pediatric presentation of these eruptions. This article discusses several of the most common acneiform eruptions, including neonatal acne and cephalic pustulosis, periorificial dermatitis (perioral dermatitis), facial angiofibromas, iatrogenic acneiform drug eruptions, and childhood rosacea.