Childhood granulomatous periorificial dermatitis: case report and review of the literature

Childhood granulomatous periorificial dermatitis (CGPD), considered a clinical variant of perioral dermatitis, typically affects prepubertal children of African descent. It is a condition of unknown etiology characterized by the presence of a monomorphic yellow-brown papular eruption limited to the perioral, perinasal, and periocular regions that histopathologically shows a granulomatous pattern. This disorder should be differentiated from other conditions as granulomatous rosacea, sarcoidosis, and lupus miliaris disseminatus faciei. We report a case of a 9-year-old boy who presented with flesh-colored perorificial papules on the face, evolving for two months. Upon treatment with topical tacrolimus for follicular eczema, an aggravation of the condition was observed. A skin biopsy confirmed the diagnosis of CGPD. Our patient was successfully treated with a combination of topical metronidazole and topical erythromycin.

Intralesional Steroids for the Management of Periorificial Granulomatous Dermatitis

A 42-year-old male with skin type I and a history of rosacea and eczema presented with crusting, erythema, and pustules distributed on the left oral commissure. Angular cheilitis was diagnosed and regular petrolatum use recommended until resolution of the lesion. Eight days later, with no improvement in symptoms, fungal and bacterial cultures were performed which resulted in the growth of cutibacterium acnes, a variant of p. acnes.

Pediatric periorificial dermatitis

Periorificial dermatitis (POD) has been documented in the pediatric population in patients as young as 3 months, with a slight predominance in girls compared to boys. Many patients have a personal or family history of atopic disorders. Periorificial dermatitis typically presents with erythematous to flesh-colored papules and rarely pustules near the eyes, nose, and mouth. Although the etiology is unknown, many patients have had recent exposure to a topical or less commonly an inhaled or systemic corticosteroid. Although steroids may initially control the skin lesions, disease often rebounds after discontinuing therapy. Diagnosis of POD is clinical. Laboratory tests are not helpful in making the diagnosis, and the histology of POD resembles rosacea. It is important to rule out other acneform diagnoses based on the age of the patient, clinical history, and presentation of the lesions. Topical metronidazole has been successful in the pediatric population. For pediatric patients with extrafacial skin lesions or more severe disease, oral antibiotics such as tetracycline, doxycycline, minocycline, azithromycin, and erythromycin can be used, depending on the age of the patient.

Azelaic Acid: Evidence-based Update on Mechanism of Action and Clinical Application

Azelaic acid is a complex molecule with many diverse activities. The latter include anti-infective and anti-inflammatory action. The agent also inhibits follicular keratinization and epidermal melanogenesis. Due to the wide variety of biological activities, azelaic acid has been utilized as a management tool in a broad spectrum of disease states and cutaneous disorders. This paper reviews the clinical utility of azelaic acid, noting the quality of the evidence supporting each potential use.

PERIORAL DERMATITIS: STILL A THERAPEUTIC CHALLENGE

Perioral dermatitis is a common and often chronic dermatosis. In its classic form, it primarily affects women aged 15 to 45 years, but there are also variants including lupus-like and granulomatous perioral dermatitis, where granulomatous form is more common in childhood and affects mostly prepubescent boys. The etiopathogenesis of the disease remains unclear, but there is a frequent finding of prolonged use of topical products, especially corticosteroids, in the treatment of rosacea and seborrheic dermatitis, preceding the clinical manifestation of perioral dermatitis. Other causes important for the occurrence of the disease include various skin irritants, as well as other physical and hormonal factors, which all share the epidermal barrier dysfunction as an underlying main pathogenic factor. Clinical presentation of papulovesicular eruption in the perioral region with a typical narrow spared zone around the edge of the lips is characteristic. Therapeutic approach should be individually addressed, depending on the severity of clinical presentation and patient's age, with special attention to patient's education and continuous psychological support. In mild forms of perioral dermatitis, 'zero therapy' is the treatment of choice. In the initial treatment period, patients with steroid-induced perioral dermatitis should be closely followed up because the rebound phenomenon usually develops after cessation of previous topical treatment. In moderate disease, treatment includes topical metronidazole, erythromycin, and pimecrolimus, whereas in more severe cases the best validated choice is oral tetracycline in a subantimicrobial dose until complete remission is achieved. Systemic isotretinoin should be considered as a therapeutic option for patients refractory to all standard therapies.

Fever, eosinophilia, and death: a case of minocycline hypersensitivity

Minocycline (MCN) is a member of the tetracycline family that is commonly used to treat dermatologic conditions such as acne and perioral dermatitis; however, it also has been associated with a number of adverse effects, including drug reaction with eosinophilia and systemic symptoms (DRESS). We report the case of a 46-year-old woman who developed a rash, fever, and eosinophilia during treatment with MCN for perioral dermatitis. Although MCN was discontinued and the patient was administered oral corticosteroids for several months, she subsequently died from multiorgan failure with giant cell myocardi-tis (GCM) and eosinophilic myocarditis found on autopsy. This article highlights a rare consequence of hypersensitivity to a commonly used drug and illustrates the importance of rapid recognition and aggressive management of MCN-induced DRESS.

Evidence based review of perioral dermatitis therapy

Perioral dermatitis presents as an eruption of erythematous papules, pustules and papulovesicles, most frequently seen in young women. Oral tetracyclines have been considered the first line treatment for years. However, recent publications have found newer agents to be efficacious. The authors performed a review of the available data in order to determine the strength of evidence supporting published therapies. A Pubmed and Cochrane Library database search for all cases, case series, and clinical trials dealing with the treatment of perioral dermatitis in English. Most cases of perioral dermatitis are self-limited, if the possible exacerbants of cosmetics and topical corticosteroids are discontinued ("zero therapy"). Many trials support the use of oral tetracyclines as a first line medication, as it significantly shortens the time to papule resolution. Topical erythromycin also reduces the time to resolution, but not as quickly. Topical pimecrolimus does not appear to decrease the time to complete resolution, but it does rapidly reduce the severity of the disease, particularly if prior corticosteroid use has occurred. The evidence supporting topical metronidazole, which is frequently used to treat perioral dermatitis in children, is relatively weak and supported only by case series and a trial showing it to be inferior to tetracycline. The evidence most strongly supports the efficacy of zero therapy, topical pimecrolimus, oral tetracycline, and topical erythromycin.

Letter: Perioral dermatitis in a child associated with an inhalation steroid

Perioral dermatitis, also known as periorificial dermatitis, is characterized by a papular rash involving the perioral, perinasal and periorbital areas of the skin. There are multiple agents that may cause these lesions, with topical steroids being the most common. Inhaled steroids are rarely implicated as a cause of perioral dermatitis. Our case is illustrative because there was a clear association of perioral dermatitis with the use of inhaled steroids and a quick response to the treatment regimen, which included discontinuation of the offending agent.

[Probiotics and children: is an integration useful in allergic diseases?]

Recent studies report that some probiotic strains are able to improve allergic diseases. For this reason, we would verify tolerability and efficacy of a industrial preparation of Lactobacillus paracasei (11,688; Proge Farm, Italy) and Lactobacillus salivarius (11,794; Proge Farm, Italy) and value their "in vitro" immunomodulatory effect. We know that, after birth, there's a persistence of Th2 immune response that predisposes to atopy, whereas commensal bacteria are able to induce a Th1 immune response that counter-balances the original response. The "in vivo" study was set up with the recruitment of 20 atopic pediatric patients treated 30 days with 2 doses of Fiorilac (Sharper, Italy), a preparation of the two strains in the proportion of 1:12. Only one patient referred significant improvements of atopic disease, 19 patients reported a good tolerability to the product and 3 patients had a regularization of intestinal function. Immunological tests showed an increase of Th1 immune response as in CD4+ lymphocytes percentage as of IL-12 and IL-10 cytokines production and a significant increase of natural killer (NK) activity, which predisposes to an active response to viral infections and neoplastic transformations.

Pimecrolimus cream (1%) efficacy in perioral dermatitis ? results of a randomized, double-blind, vehicle-controlled study in 40 patients

BACKGROUND

Perioral dermatitis (POD) is a common skin disease and difficult to treat. Pimecrolimus cream (1%) successfully controls atopic eczema.

OBJECTIVE

Our aim was to investigate its efficacy in POD.

STUDY DESIGN

Single-centre, randomized, double-blind, vehicle-controlled study including 40 POD patients with a 4-week treatment and a 4-week follow-up. Efficacy was assessed by a novel Perioral Dermatitis Severity Index (PODSI) and Finlay's Dermatology Life Quality Index (DLQI).

SETTING

Outpatient clinics of a large dermatological hospital in Munich, Germany.

RESULTS

During treatment, the PODSI was significantly lower in the pimecrolimus group compared with vehicle (P = 0.005-0.02) whereas at follow-up, no significant differences were observed. At week 2, the responder rates (> or = 50% PODSI improvement) were 50% with pimecrolimus cream (1%) and 25% with vehicle (P = 0.095). DLQI was improved in pimecrolimus group compared with vehicle.

CONCLUSION

Results suggest that pimecrolimus cream (1%) effectively treats acute-stage POD.

Case of childhood granulomatous periorificial dermatitis in a Korean boy treated by oral erythromycin

Childhood granulomatous periorificial dermatitis (CGPD) is a disease presenting most commonly in prepubertal children as yellow-brown papules limited to the perioral, perinasal and periocular regions. The condition is benign, self-limiting and is not associated with systemic involvement. We herein report a case of an 11-year-old Korean boy with multiple, asymptomatic, monomorphic, red-to-yellow-colored papular eruptions on the perioral areas of 7-month duration. Histopathological examination revealed upper dermal and perifollicular granulomatous infiltrate. After using oral erythromycin 500 mg daily for 1 year, the condition resolved completely without leaving a scar.

Periorificial dermatitis in children and adolescents

BACKGROUND

There has been very little evaluation of the history, morphology, or disease course of perioral/periorificial dermatitis in children.

OBJECTIVE

We sought to elucidate the clinical manifestations and treatment outcomes in this condition.

METHODS

A retrospective chart review with telephone follow-up was used to study 79 children and adolescents.

RESULTS

Patients ranged from 6 months to 18 years of age. The average duration of the rash at presentation was 8 months. Seventy-two percent had a history of topical, inhaled, or systemic steroid exposure. Seventy percent of patients had perioral involvement, 43% perinasal, and 25% periocular involvement. A perivulvar rash was reported in 1% of patients. Treatment with topical metronidazole was associated with clearing on follow-up examination.

LIMITATIONS

This is a retrospective study without case controls and is subject to interviewer and memory bias.

CONCLUSION

Perioral dermatitis appears at all ages in childhood and adolescence and may be associated with topical corticosteroid use. It may be responsive to topical metronidazole in children and adolescents and is more appropriately termed periorificial dermatitis.

Contact allergy to para-phenylenediamine in a permanent eyelash dye

We present the case of a 30-year-old atopic lady with a known history of intolerance to several materials, including dark stockings, who developed a severe dermatitis on the eyelids and peri-orbital regions, as well as a conjunctivitis after having her eyelashes tinted by a beautician with a permanent black eyelash and eyebrow dye (Combinal, Dr Temt Laboratories, Austria). Patch tests revealed positive reactions to para-phenylenediamine (PPD), both diluted 0.01% and 1% in pet., to the eyelash dye (tested semiopen as is) and to some of the azo-dyes tested. The permanent eyelash dye did contain PPD, the use of which is illegal but seems to be a common practice. The patient had most probably been sensitized through nylon stockings containing azo-dyes, with PPD itself cross-reacting to them. With the growth in popularity of tattooing and permanent make-up, doctors should be aware of the new uses of this old allergen. Moreover, although many manufacturers have made great efforts to improve cosmetics concerning their safety, some of them remain uninformed about cosmetic legislation or do not respect it at all. Because many of these products are acquired via internet, lack of legislation about this shopping modality is also a serious problem.

Photodynamic therapy for perioral dermatitis

BACKGROUND

Treatment of perioral dermatitis (POD) consists of topical steroids, oral antibiotics, and topical antibiotics.

OBJECTIVE

To evaluate the safety and efficacy of photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA) in the treatment of POD.

METHODS

A split-face 21-patient study was conducted in which one side of the face was treated 4 times weekly with ALA PDT (30-minute ALA incubation) with blue light activation and the other side with topical clindamycin. Lesions were counted and photographs were taken before and after the final treatment. Patient satisfaction was also evaluated.

RESULTS

Fourteen patients (66.7%) completed the study. Facial sides treated with ALA PDT achieved a mean clearance of 92.1% compared to 80.9% for the clindamycin-treated sides. The difference was significant (P=0.0227). The mean patient satisfaction level for the ALA PDT-treated side was 4.4 (1-5 scale).

CONCLUSION

ALA PDT may be a promising alternative to antibiotics for the treatment of POD.

The use of topical azelaic acid for common skin disorders other than inflammatory rosacea

Topical azelaic acid (AzA) is approved for the treatment of acne vulgaris and inflammatory (papulopustular) rosacea. Because of diverse mechanisms of action that correlate with potential therapeutic benefit, AzA has been used to treat several common dermatoses including acne vulgaris, inflammatory rosacea, erythematotelangiectatic rosacea, perioral dermatitis, melasma, and postinflammatory hyperpigmentation. This article reviews the therapeutic use of topical AzA for the treatment of common skin disorders other than the US Food and Drug Administration (FDA)-approved indications of acne vulgaris and inflammatory rosacea.

Childhood granulomatous periorificial dermatitis: lupus miliaris disseminatus faciei in children?

BACKGROUND

Childhood granulomatous periorificial dermatitis (CGPD) is a granulomatous disease characterized by monomorphous, small papular eruptions around the mouse, nose and eyes, and is thought to be closely related to perioral dermatitis. This condition has always been believed to occur more commonly in dark-skinned patients; however, recent observations have revealed CGPD to occur also in white patients.

OBSERVATION

We report an 11-year-old Japanese boy with the characteristic features of CGPD. Although sarcoidosis and acne/granulomatous rosacea could be differentiated from CGPD, we could find no essential differences between CGPD and lupus miliaris disseminatus faciei (LMDF). The cases of LMDF in children, which were recorded in the Japanese literature, had highly similar clinicopathological features to those of CGPD. This case responded dramatically to topical tacrolimus in combination with the oral administration of minocycline.

CONCLUSIONS

The entity 'facial idiopathic granulomas with regressive evolution' is considered to include LMDF (a common adult form), CGPD (a rare childhood form) and perioral dermatitis (a peculiar form exacerbated by topical corticosteroids). Topical tacrolimus may be recommended as one of the therapies for LMDF as well as CGPD.

Density of Demodex folliculorum in perioral dermatitis

The role of Demodex folliculorum in perioral dermatitis is not satisfactory explained. Our purpose was to assess the density of D. folliculorum in perioral dermatitis and evaluate the relationship of the mite count to previous therapy with topical steroids. A standardized skin surface biopsy of the chin was performed in 82 female patients with perioral dermatitis and in 70 control female subjects. Patients who received previous topical steroid therapy had a significantly higher mite density than the patients who had received no topical steroids (p<0.001). In the latter group of patients, the mite density did not differ significantly from that of the control group (p=0.629). Mite density increased significantly with the length of treatment with topical steroids (p<0.001). Our results suggest that increased density of D. folliculorum in perioral dermatitis is a secondary phenomenon, associated with topical steroid therapy.

Critical Appraisal of Reports on the Treatment of Perioral Dermatitis

BACKGROUND

Presently, problems exist with the rationale of oral therapy and the nature and indication of topical and accompanying treatment of perioral dermatitis.

OBJECTIVE

Providing the basis to overcome these problems by a quality evaluation of treatment reports and assessment of the consistency of treatment experience.

METHODS

Sources were Medline (1964-2004), Embase (1966-2004), the Cochrane Central (1971-2004) and 526 references of 3 textbooks, 2 recent reviews and 30 papers on perioral dermatitis. Thirty English and German articles were selected. These studies were evaluated according to principles of evidence-based medicine and related criteria. Evaluation of 28 papers was carried out by the authors and of our own 2 papers by 2 other reviewers. Consistency of results was qualitatively assessed by the authors.

RESULTS

There were only 2 therapeutic trials of medium-range quality. The other studies were of low quality. Consistency was noted concerning treatment with oral tetracycline (with 1 exception), discontinuation of topical corticosteroids and cosmetics and, to a lesser extent, regarding no therapy. There was inconsistency in respect to topical therapy.

CONCLUSION

The presented data help to interpret and conduct studies on the treatment of perioral dermatitis.

Acneiform facial eruptions: a problem for young women

OBJECTIVE

To summarize clinical recognition and current management strategies for four types of acneiform facial eruptions common in young women: acne vulgaris, rosacea, folliculitis, and perioral dermatitis.

QUALITY OF EVIDENCE

Many randomized controlled trials (level I evidence) have studied treatments for acne vulgaris over the years. Treatment recommendations for rosacea, folliculitis, and perioral dermatitis are based predominantly on comparison and open-label studies (level II evidence) as well as expert opinion and consensus statements (level III evidence).

MAIN MESSAGE

Young women with acneiform facial eruptions often present in primary care. Differentiating between morphologically similar conditions is often difficult. Accurate diagnosis is important because treatment approaches are different for each disease.

CONCLUSION

Careful visual assessment with an appreciation for subtle morphologic differences and associated clinical factors will help with diagnosis of these common acneiform facial eruptions and lead to appropriate management.

Perioral Angioedema Associated With Angiotensin-Converting Enzyme Inhibitor

BACKGROUND

Angioedema is a non-pruritic swelling usually limited to the skin and mucous membranes of the face and perioral soft tissues. It can be life threatening but usually is not, and can be managed with conservative medical treatment unless the airway is endangered. Recent reports suggest that angiotensin-converting enzyme (ACE) inhibitors can predispose and/or precipitate angioedema, with a predilection toward patients of African American ancestry.

METHODS

This case report involved a 65-year-old African American female who was being treated surgically for localized chronic periodontitis. The procedure was performed without incident, and the patient was alert and stable when released. The next day, the patient called and reported that her lips were swollen. She stated that this had happened a number of times over the past several years, sometimes related to eating shellfish and other times without any known precipitating factor. All previous episodes of perioral swelling occurred after ACE inhibitor therapy had been initiated.

RESULTS

The patient was in no distress, with no other site involvement. She was prescribed oral hydroxyzine and her appearance returned to normal after 5 days. Although the patient had experienced previous episodes of angioedema, none had been in response to any dental procedure. She was referred to the Allergy and Immunology Clinic for skin testing, the results of which were negative to shellfish with good controls. Other potentiating etiologies were also ruled out by the allergist.

CONCLUSIONS

Angioedema is a recognized possible side effect of ACE inhibitor therapy. The exact mechanism by which ACE inhibitors induce angioedema is not known, although the risk of occurrence is much greater in African Americans. Practitioners should be alert to this potentially fatal condition in patients who take ACE inhibitors or the newer angiotensin II receptor blockers (ARBs).

Aspects of oral syphilis

The incidence of sexually transmitted diseases recently increased in the United States and Europe due to migration, increase in high-risk behavior, and abandonment of safer sex practices at the advent of anti-retroviral combination therapy for human immunodeficiency virus infection. This article presents four cases of primary oral anti perioral syphilis with differential diagnoses. It is important to bear this reappearing infection in mind to avoid latent infection. Resembling common oral infections, the primary affect disappears spontaneously, and the infection enters the second stage. The patient remains infected, may further spread the disease, and risks severe organ damage from long-standing infection. The antibiotic cure is inexpensive and safe and spares the patient mucous patches and gumma residuals, apart from severe general sequelae such as thoracic aorta aneurysm and neurosyphilis. However, compliance problems jeopardize clinical and serologic follow-up. The growing syphilis incidence prompts the commemoration of Dr Moriz Kaposi and his dispositive 1891 book Pathology and Therapy of the Syphilis. Moriz Kaposi is acknowledged as one of the heads of the Vienna School of Dermatology, a superb clinician, and renowned teacher.

[Folliculitis barbae in herpes simplex infection]

A 60-year-old male athlete developed a folliculitis in the beard region after several competitions. After identification of herpes simplex antigen within the lesions, systemic therapy with acyclovir led to rapid improvement. In folliculitis resistant to antibiotic and anti-inflammatory therapy, viral and mycotic infections as well as eosinophilic folliculitis should be considered as differential diagnostic possibilities.

Granulomatous periorificial dermatitis

Granulomatous periorificial dermatitis (GPD) is a distinct facial eruption in prepubertal children that should be distinguished from granulomatous rosacea, perioral dermatitis, and cutaneous sarcoidosis. We describe a case of GPD and review the key distinguishing features of this condition.

Periokulare Dermatitis. Periocular dermatitis

BACKGROUND

Perioral dermatitis paradoxically sometimes spares the entire perioral region. There may be isolated periocular involvement (periocular dermatitis).

PATIENTS/METHODS

The records of 23 patients with only periocular dermatitis were reviewed with respect to the following parameters: clinical findings, history of atopy, topical facial treatment, prick and patch tests, CAP-SX1, previous treatment, time to healing and relapses. 23 patients with no history of periocular dermatitis were matched for age and sex (case-control study).

RESULTS

The predominant clinical finding in the affected group was micropapules primarily in the lateral corner of the eye and lower eyelid. The groups differed significantly (p < 0.05) with regard to the history of atopic diseases and reactive prick tests. 22 patients regularly used face-care or eye-care products. These patients did not differ significantly from the control group with regard to frequency and type of product used. 6 patients had been previously treated with topical corticosteroids. The time to healing was 2-8 weeks (median: 4 weeks).

CONCLUSIONS

Periocular dermatitis is a variation on perioral dermatitis, where-by similar pathogenetic factors are observed. The elimination of topical corticosteroids and the gradual reduction of skin-care products regularly lead to clearing of the condition.

Extrafacial and generalized granulomatous periorificial dermatitis

BACKGROUND

Granulomatous periorificial dermatitis is a well-recognized entity presenting most commonly in prepubertal children as yellow-brown papules limited to the perioral, perinasal, and periocular regions. The condition is self-limiting and is not associated with systemic involvement.

OBSERVATIONS

We reviewed the medical charts of 5 healthy children presenting with extrafacial granulomatous papules in addition to the typical periorificial papules. These extrafacial lesions were clinically and histologically identical to the facial lesions, were self-limiting, and were not associated with systemic involvement. Resolution seemed to be hastened with the use of systemic antibiotic therapy in 4 of the 5 patients.

CONCLUSIONS

Extrafacial lesions can occur in granulomatous periorificial dermatitis and do not appear to adversely affect the duration, response to therapy, or risk of extracutaneous manifestations. Overly aggressive evaluation and inappropriate systemic therapy should be avoided.

Past administration of beta-lactam antibiotics and increase in the emergence of beta-lactamase-producing bacteria in patients with orofacial odontogenic infections

OBJECTIVE

The purpose of this study was to determine the current status of beta-lactamase-producing bacteria in orofacial odontogenic infections.

STUDY DESIGN

Microbiologic data regarding purulent exudate from 111 cases with orofacial odontogenic infections were analyzed in relation to the past administration of beta-lactams.

RESULTS

beta-lactamase-producing bacteria were isolated more frequently from the beta-lactam-administered group (38.5%) than from the beta-lactam-nonadministered group (10.9%; P <.005), and they were isolated more frequently as the duration of administration increased. The predominant bacteria isolated included Prevotella (the most frequent isolate), viridans streptococci, Peptostreptococcus, and Fusobacterium, and 7.1% of total isolates produced beta-lactamase. Penicillin and cefazolin worked well with beta-lactamase-nonproducing Prevotella but were remarkably affected by beta-lactamase-producing Prevotella. Cefmetazole, sulbactam/cefoperazone, and imipenem worked well against both types of Prevotella.

CONCLUSIONS

beta-lactams are still suitable for the first antimicrobial therapy in the treatment of these infections. However, because past beta-lactam administration increases the emergence of beta-lactamase-producing bacteria, beta-lactamase-stable antibiotics should be prescribed to patients with unresolved infections who have received beta-lactams.

Balm mint extract (Lo-701) for topical treatment of recurring herpes labialis

A double-blind, placebo-controlled, randomized trial was carried out with the aim of proving efficacy of standardized balm mint cream [active ingredient: 1% Lo-701--dried extract from Melissa officinalis L. leaves (70:1)] for the therapy of herpes simplex labialis. Sixty six patients with a history of recurrent herpes labialis (at least four episodes per year) in one center were treated topically; 34 of them with verum and 32 with placebo. The cream had to be smeared on the affected area four times daily over five days. A combined symptom score of the values for complaints, size of affected area and blisters at day 2 of therapy was formed as the primary target parameter. There was a significant difference in the values of the primary target parameter between both treatment groups: verum 4.03 +/- 0.33 (3.0); placebo 4.94 +/- 0.40 (5.0); values given are mean +/- SEM (median) of the symptoms score on day 2 of therapy. The tested formulation is effective for the treatment of herpes simplex labialis. The significant difference in the combined symptom score on the second day of treatment is of particular importance having in mind that the complaints in patients suffering from herpes labialis are usually most intensive at that time. In addition to the shortening of the healing period, the prevention of a spreading of the infection and the rapid effect on typical symptoms of herpes like itching, tingling, burning, stabbing, swelling, tautness and erythema, the balm mint cream has a further advantage. The different mechanism of action of the balm mint extract rules out the development of resistance of the herpes virus. Some indication exists that the intervals between the periods with herpes might be prolonged with balm mint cream treatment.

Perioral dermatitis in children

Perioral dermatitis is a unique skin disorder of childhood. Its exact origin is unknown; it is probably an idiosyncratic response to exogenous factors such as the use of a topical fluorinated corticosteroid or other substances on the face. It is uncommon but not rare. The age of affected children has ranged from 7 months to 13 years, with the median being in the prepubertal period. Boys and girls, blacks and whites are equally affected. Clinical features include the following: (1) absence of systemic symptoms; (2) periorificial distribution (perioral, perinasal, periorbital); (3) skin lesions that consist of flesh colored or erythematous inflammed papules, micronodules, and rare pustules; and (4) variable pruritus. Laboratory tests are negative. Histologically, it is indistinguishable from rosacea; there is a superficial perifollicular granuloma consisting of epitheliod cells, and lymphohistiocytic infiltrate, with occasional giant cells. The disease waxes and wanes for weeks and months. Treatment consists of discontinuing topical fluorinated corticosteroid use if any, and using topical metronidazole alone or in combination with either oral tetracycline or erythromycin depending on the child's age. A low-potency topical steroid may also be used to suppress the inflammation and to wean off the strong steroid. Perioral dermatitis in childhood is probably a juvenile form of rosacea.

Perioral dermatitis in children--clinical presentation, pathogenesis-related factors and response to topical metronidazole

BACKGROUND

Perioral dermatitis, a common skin disorder in young women, is rarely described in children.

OBJECTIVE

This study elaborates the clinical features of perioral dermatitis in children as well as possible pathogenetic mechanisms and the response to topical metronidazole.

METHODS

Seven children (4 females, 3 males between 4 and 12 years of age) were evaluated and dermatological examination was carried out. Pretreatment with topical corticosteroids was documented. Skin prick test with a panel of six common aeroallergens was performed in all children. All children were screened for gastrointestinal colonization with Candida albicans. Patients were treated with topical metronidazole 1% during the first 2 weeks. From the 3rd week on 2% metronidazole was used.

RESULTS

In all but one child topical corticosteroids had been used in the face prior to the first presentation at our outpatient department suggesting a possible pathogenetic role. An association with atopy or intestinal candida colonization was not found. In all children skin lesions resolved after 3-6 months. The children remained free of symptoms over an observation period of 2 years.

CONCLUSION

Perioral dermatitis has to be considered as differential diagnosis in children presenting with erythematous papules and papulovesicles in typical locations. Metronidazole proved to be effective and safe in the treatment of perioral dermatitis in children. Atopy and gastrointestinal colonization with C. albicans do not seem to play a role in the pathogenesis of perioral dermatitis.

Childhood granulomatous periorificial dermatitis

A case of childhood granulomatous periorificial dermatitis is described. This disorder occurs predominantly in prepubertal black children and is characterized by a monomorphous, papular eruption occurring around the mouth, nose, and eyes. It is benign and self-limited. Treatment may include topical metronidazole in young patients and tetracycline in those over 8 years of age.