Perioral Dermatitis - Eczema, Meet Acne

By Sarah Villafranco, MD
Posted in Blog, on April 18, 2014

I have a lot of medical words in my brain, but few have been on my mind as consistently over the last several years as perioral dermatitis. Having suffered with it myself, I have done extensive research, both didactic and practical, often with myself as the guinea pig, and I am happy to share what I have learned.

What is it?

Perioral dermatitis (PD) is a very common condition of the facial skin (perioral = around the mouth), especially in women of menstruating age. It is frequently undiagnosed or misdiagnosed, and acts like a cross between acne and eczema. The fact that these two diseases behave very differently may, in part, explain why it is so poorly understood, and so troublesome to treat.  With continued research, and after talking to many people who suffer with the condition, I actually believe that PD is an endpoint that arises from a unique, fluctuating set of circumstances and predispositions in each patient.   As with a mathematical equation, different numerical combinations can add up to the same sum.  This is true of PD as well.  In some cases, it is clear cut, and directly linked to a particular cause.  But in most patients, the causes are multiple, uniquely combined,  and ever-changing  (making it even more difficult to treat!).

It varies in severity. In mild cases, it consists of patches of slightly bumpy, red or irritated looking skin, often with some mild flaking of the skin around the mouth, chin, and nose. (Some women experience symptoms near the outer corners of the eyes as well, though this is a less common location.) In more severe cases, the skin becomes very inflamed and angry looking in those areas, with flakes or scabs that can bleed or become infected.

Why does it happen?

There are many theories about the cause of perioral dermatitis, none of which are definitive. The most commonly proposed cause is the use of steroid facial creams, which are prescribed ubiquitously by western dermatologists. Other possible causes include fluoride toothpaste and sodium laureth sulfate. Exacerbating factors may include heavy creams or oils, cinnamon flavor/scent, and exposure to cold and sun.  I think we will probably learn in the future that there is a large hormonal component to the condition, as well.  It tends to resolve on its own as we age; it is fairly rare to see it over age 50, when our hormones simmer down and even out a bit.

My Story

I began having trouble with PD at age 36, a fairly typical age for women to have symptoms (generally age 20 to 45). My symptoms were also typical, and included redness, small bumps, and flaking of the skin around the chin, mouth, and nose.

When I first started studying natural skincare, especially with regard to this issue, I experimented a LOT on my own face. From yogurt masks to apple cider vinegar to nourishing oils to heavy creams, I explored options. None seemed to help consistently, and some (oils and heavy creams) made things worse. Hormone fluctuation definitely affected my symptoms, which were unfailingly worse in the days before my period.

I went to a local dermatologist after about 4 months. I told her I had perioral dermatitis. She agreed, and prescribed a topical antibiotic. As she wrote the prescription, I asked her if she had any experience with natural remedies, such as green tea extract, probiotics, and apple cider vinegar. She told me she was unfamiliar with homeopathy.  

I tried the antibiotic lotion for four days, and my symptoms got so much worse that I decided to be a bad patient and stop the medication. That’s when I got serious about figuring out a plan. Granted, this was not a randomized, controlled experiment. I made a bunch of changes at once, and could not tell you which one made the difference in my skin.

But here are the things I changed:

 

  • I stopped fluoride toothpaste (I switched to this one, which is also free of sodium laureth sulfate- Seafresh Toothpaste by Jason)
  • I stopped using sodium laureth sulfate in my hair care products.
  • I started evening primrose oil supplements (I like these - Barlean's Evening Primrose Oil. They also helped moderate my PMS symptoms, and who can complain about that?)
  • I took a less-is-more approach with my skin, which I continue to follow. I use this soap once or twice a day - Osmia Organics Black Clay Facial Soap - and I limit exfoliation in the perioral region (counter-intuitive, I know). After cleansing, I follow with this water-based serum -Osmia Organics Active Gel Toner. I leave the serum on for 30 seconds, and then follow with this cream - Osmia Organics Purely Simple Face Cream - applied sparingly around the mouth and chin.

 

While I make no claims about whether these steps will work for a person with PD, these minimally invasive changes have improved my symptoms dramatically. It took about 6 months (less invasive measures often require more patience), and I occasionally have symptoms around my cycle, when the dermatitis is visible up close in a mirror. Most of the time, people squint and stare when I tell them I have the condition, which tells me it is not usually noticeable. Wearing makeup (even a dab of powder, as I don’t wear any foundation) will make the dermatitis more visible, as well. 

With any of the lifestyle changes or products mentioned above, results may not be visible for 3-6 weeks - it is a condition that takes a long time to change, and requires patience and commitment on your part.  

How should I treat?

Dermatologists will treat this condition with topical or systemic (oral) antibiotics, over a course of 6-12 weeks. There is a moderate success rate with this course, as well as a relatively high relapse rate.   Avoid steroid creams at all cost, as they are suspected of having a causative relationship to PD. I have found, whether antibiotics are involved or not, that relapse is very likely without lifestyle modifications.

The first two changes I suggest are eliminating fluoride in toothpaste, and sodium laureth sulfate (SLS) in oral, facial, and hair care products. A healthy, plant-based diet, with appropriate supplements, such as evening primrose oil, and attention to beneficial fats and grain or legume-based proteins will make a positive change in almost any skin type. And, sufficient water intake (spring water is the best) will help maintain intracellular water levels in the skin, as well.

As for skin care, I choose my products because I love my products, and I know who made them and with what ingredients. But, the point is that you need to RESIST the urge to scrub your face and heap products on it. Perioral dermatitis wants to be left ALONE. It does not like heavy creams or oil-based serums. It wants water-based, simple products, and some peace and quiet.  

I can't promise you our products will work for you!  But, we have had a LOT of people say their symptoms have decreased substantially (if not dramatically).  Whether you purchase product from us or not, I am available by email for questions any time, and will do my best to respond to them within a week or so.  And, if you've purchased our products and want to touch base about how they're working for you, we are here to listen, and help you make adjustments if necessary.

Remember, above all – do less.  And, for your own sanity, keep track of the things you do, and try to think of them as pieces of a management strategy for PD, rather than looking for one "miracle cure".  It will likely be a condition that does not fully go away until it is good and ready, so it can feel more frustrating than it needs to if you are out to CURE it, rather than decrease the symptoms and render them manageable.  Make sense?

And, now that you've read the basics, maybe our blog post about PD Frequently Asked Questions will help with any other questions you may have - thanks for reading!

 

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Comments

Hi, I’m 16 and i’ve had PD for about 6 months. I have it around the corners of my nose and in my nostrils a little bit. I was prescribed ‘Elidel’ as well as 6 weeks of Doxycycline, which I finished roughly a week ago. However, I’ve noticed over the last few days that it is still sprouting up in random spots near my mouth (my doctor said it is possible for PD to spread by the touch). I have eaten a vegetarian diet for 5 months in the hopes that it will get better, but to no avail. I recently became vegan and have been for over a month, however I’m still having difficulty reducing my condition. Being a teenage girl, not only is it rare at my age but it’s also very embarrassing and makes me feel extremely self-concious! With my condition, I have not a clue what could’ve caused this. I know it wasn’t stress, and I don’t put heavy creams on my face in this area. This area however was the oiliest on my face, could that be a factor? I feel as though the consistent Elidel and Doxycycline has helped a lot, but its getting worse since my prescription ended? Just curious as to what anyone suggests. Thanks! x

Rayray on February 03, 2016

Hi! I think I have PD; going to ND in two hours. Mine is around my mouth, starting to show up on my nose, and it looks like the left side of my face is flaring up (cheek area). I also woke up today with rashes on some of my fingers between my knuckle and joint. Is it possible for PD to spread like this?

Also, I read a little about pyorre disorder and wonder if I could have that. I have pilaris ketosis on my upper arms and my ND is working on my thyroid. I’m also 9 months Post partum and am nursing so hormones could be a factor for me.

Do you think the same skin regime will work on my PK? My 4 year old has the bumps from KP as well. Will it help him? Any insight into KP?

Thank you – Cyndi

Cyndi on January 23, 2016

Hi I am 37 and have mild peri oral dermatitis. I also get it in the corners of my eyes sometimes. As I’ve got older and had a baby my skin has become thinner and I have fine lines round my eyes. I try not to use any products with fragrance or anti ageing chemicals or even essential oils as over a week or so the redness gets worse round my mouth. I’m presently using Cetraben cleansing gel and moisturiser. However my skin feels both tight and dry and greasy! I get blocked hard spots around my chin which seem to be solid blocked oil – yuck! Really confused how to proceed. I used nothing on my skin at all for three months a few years ago and I still had the red ring round my mouth. Any suggestions and do you ship to the uk?

Emma on January 21, 2016

Maybe someone could help me, but I only experience my PD when I have dated someone. The last time I had PD was about two years ago, but it came back recently when I got back together with one of them. I’m not sure why I only get it really bad when in with one of them, but it is very frustrating. I have tend to notice I get pimple like bumps above my lip/on my lip and I’m not sure if that it actually my PD coming it. I usually have a few of those bumps on my lip a month, but they go away. I’m pretty reluctant with trying antibiotics because it’s either hit or miss. If I do get antibiotics for it, is there a good possibility I won’t experience PD again? I don’t want to be in fear of dating people just because I’m scared my PD will flair up :(

April on January 15, 2016

@ Marie – it’s on Amazon here: http://www.amazon.com/Jason-Fresh-Toothpaste-Spearmint-Ounce/dp/B000FGDIRQ/ref=sr_1_1?ie=UTF8&qid=1452575262&sr=8-1&keywords=jason+seafresh+toothpaste

@ Keysha – I’m so sorry for your frustration – it’s so upsetting when you’re on what you think is a path to healing and it turns out to be the wrong path. I would say the lifestyle changes in this article and the other PD article on our blog are the most important things to do right away – get rid of fluoride and SLS immediately. If you want to try any Osmia products, I would start with the Black Clay Facial Soap, and just start by ordering a sample. Also, be sure to support your skin with a healthy diet and stress management – those things matter way more than we could ever imagine. Sending lots of love and support! – SV

@ Lexie and KT – I totally agree that hormonal contraception can play a huge role in PD for some people. Unfortunately, you have to experiment a bit to figure it all out. If you need to be on contraception, you might consider a topical form, like the Nuvaring or Mirena – those may achieve lower systemic levels of hormone fluctuation. You can also try taking Oona, an herbal hormone supplement that helps even things out (for me at least). Be patient and kind with yourselves, and remember your skin is not doing this to make you mad! Sending love – SV

@ Steph – Amazing research and advice. Way to be your own health advocate (and detective!!).

@ Sarah – I have found coconut oil to be exacerbating to my PD, almost without exception. Feel free to try the Black Clay Facial Soap and Purely Simple on your daughter – they are safe for her, and might help clear things up a bit. Love to you both – SV.

@ Amy – So much information, and so little certainty = so frustrating! I would think these products would be fine for both acne and eczema, as PD is really a cross between the two. You can always order samples on our site so you can try before you buy. And be sure to make the recommended lifestyle changes – those are so critical for long term change. You might also order a sample of our Spot Treatment, in case any “spots” crop up while you’re trying new products. Wishing you all the best – SV.

@ LC and Jo – Thank you so much for sharing, and excellent job healing yourself!! – SV

Sarah Villafranco, MD on January 11, 2016

Where do can you purchase the Sea Fresh Toothpaste by Jason ?

Marie Wells on January 11, 2016

I am a 36 year old black female with sensitive and problem skin problems. In my teens I suffered my acne, 20’s I had eczema and roseca and now I have been struggling with PD for almost 5 years now. I know it started from me using Locoid a steroid cream for about 3 years. I was put on Doxycycline and tried several topical creams such as protopic, metro gel, finacea, and etc but every time I would use one of those creams on the area around my mouth it would make it worse. Now my GP advised me to stop using the doxycycline because its affecting my kidneys so Im back to square one recently I have been researching natural remedies and I had dried mother’s apple cider vinegar which helped a little. If any one has any suggestion please help.

Keysha on January 09, 2016

Re: KT – yes I think that my PD is 100% linked to my birth control pills. I was on name brand Ortho Cyclen for years. The pharmacy switched me to Mononessa generic. My pd is a mess. I just figured it out for sure tonight. I’m going off of it. I also think I aggravated it by unknowingly applying hydrocortisone cream, not realizing it was the PD once again. No more pills for me. My face hurts :-( looks awful. Good luck :-))

Lexie on January 07, 2016

I had PD about two years ago. It came up randomly and worsened when I tried to use steroid creams to get rid of it. The doctors gave me many different creams that just made it worse. Eventually, I did some research and decided to cut out all products with sulfates. So I changed my toothpaste, soap and shampoo…. but still nothing happened. Then, I realized that my laundry detergent had sulfates in it…. So I re washed my bed sheets in this all natural, sulfate free detergent. To my surprise and delight, my skin completely cleared up within less than a week and I have not had an outbreak since (I still continue to use sulfate free products). So for everyone out there who has PD and uses laundry detergent with sulfates, try switching detergents! Worked super well for me (and coincidentally, for my boyfriend about a year later).

steph on January 03, 2016

I got the soothing starter set and really love how it is helping my skin. Thank you for the information provided on your site, it is the best out there . I have made all the changes that you suggested, toothpaste, shampoos, and evening primrose oil. I have also been using frankincense oil mixed with coconut oil. Would that be considered the type of oil based product I should stay away from? Also, my 3 year old daughter is suffering from perioral dermatitis the same time I am. It is so strange, as I have never dealt with it before. We both were using a topical steroid on our face for a dry spot that started under our noses ( totally weird that happened at the same time). Once I realized steroids are bad for face we stopped cold turkey and the perioral. Popped up on us both. I feel terrible and just can’t get hers under control.

Sarah on December 28, 2015

Hi I was wondering if this is safe to use on acne prone and eczema. Because unfortunately for I have this eczema and acne. I have had all of these since a was little. Expect my PD is very very very itchy to where I have to scratch it and then it becomes inflamed red bumpy and all that stuff. I am currently using a cream that’s a antioxidant. Wondering if that’s good. And is going gluten free the way to go then? Also I have been taking birth control for the past 2 years and because my acne was TERRIBLE before now it’s pretty much gone I get a few here and there but I heard this causes PD but how can I control my acne if I stop taking BC. It’s all very frustrating and I don’t know what to trust or what to do.

Amy on December 25, 2015

I cured my perioral dermatits without antibiotics. I did not want to keep using antibiotcs as they kill off your good gut bacteria. I stopped drinking kombucha due to high floride content in tea. I avoided all dairy, tomatoes, eggs, nitrates and basically all foods that cause a histamine response. You can look these foods up on the net. I then started taking Hcl and digestive enzymes. It took about 3 weeks for the rash to totally dissappear. This helped me and I hope this will be of help to you.

LC on December 16, 2015

Going Gluten free and adding in vitamin B2 addressed my PD. I have never used conventional treatments but topically I use Mukti Calendula cream or Bioeffective Gel (aloe vera with conifer needles).

Jo on December 14, 2015

I’ve been struggling with a periorificial dermatitis for over 3 months now. At first it was just on the corner of my mouth. Now it has spread up around my mouth to my nose, inside my nostrils slightly, and it now surrounds my eyes and is across the bridge of my nose. I was prescribed Seasonique oral contraceptive, and after about 3 months of being on the pill I started getting these bumps. I was just on the sugar pills for the first time in 3 months (on this pill you only get a period 4 times a year) and FOR ONCE IT STARTED TO CLEAR!! I switched to my OLD birth control pill, and now things are worsening yet again. Is anyone else taking oral contraceptives!? I believe there is a clear link between the pills and my skin. I have tried EVERYTHING, except going to the doctors because I do NOT want to take antibiotics… but I made an appointment for Monday. The Derm. is not available until February… so wish me luck.

KT on December 01, 2015

Caitlyn - You don't rinse off the Active Gel Toner. That said, you may want to introduce only one product per week, as your skin is probably confused at the moment. So, I would add the Purely Simple or the Black Clay Facial Soap first, then the other (after 4-5 days if your skin is tolerating it), and the gel toner last. If you have specific questions, just email helposmiaorganics.com and we will help tailor your routine. Best of luck – be patient, consistent, and kind to your skin. -Sarah.

Sarah Villafranco, MD on November 23, 2015

Hi Sarah. I started a steroid cream for my “acne” prone skin. A couple days late I started noticing red, flaky, dry, burning and itching skin around my mouth, chin, nose, and a little on my cheeks. I first thought it was just some eczema so I moisturizer. When I put the moisturizer on my face it just burned. I went online and searched my symptoms and self diagnosed myself with PD. I am truly hoping your products help me. But reading your article you said that you put in the active gel and leave it on for 30 seconds and then put on the purely simple cream . Do you rinse off the active gel and then put on the cream or do you put on the gel wait 30swcinds and apply the cream over the gel? If you could get to me as soon as you can I’d appreciate it. Thank you!

Caitlyn on November 23, 2015

I think my one year old may have this, but she doesn’t use toothpaste, shampoo, soap anything.
So now what? Anyone have any helpful tips?

nicolthepickle on November 12, 2015

Thank you for sharing your story. I am 51 years old. I have been grain and sugar free for 3 years. I eat no processed food at all and everything I put on or in my body is organic and natural. There is nothing I put on my body that I could not ingest as well! So why perioral dermatitis for me? All the things I have been told to do, I already do. It could make me feel hopeless but I do not. I believe my body is detoxing. There is something not right and it is making its way out of my body through my face! I changed my diet 3 years ago because I was diagnosed with SIBO (Small intestinal bacterial overgrowth). My stomach has been better the past 6 months than it has ever been before, but I truly believe that my rash is due to candida of some sort and what you said is so true! I need to manage symptoms best I can and let this run its course. I refuse to take antibiotics when I have worked so hard to rebuild good bacteria in my gut, especially when I read that most cases need to be retreated with antibiotics later on. Thank you very much but I am not getting on that merry go round. I meditate, exercise, do yin yoga, accupuncture and massage every week. I am not comfortable with this itchy, burning unsightly rash, but I have to co-exist with it for now. Thank you for all of your suggestions.

Maria on October 29, 2015

Hello. I will be 24 this month, and I believe I have this condition. It popped up only a week or so ago. I already don’t use flouride or sls in any of my care products.

My rash is mostly on the left side of my mouth, with a few spots on the right. There are a bunch of tiny bumps, and the main area that is irritated is flaky, gets itchy, is red and looks utterly disgusting. I’m embarrassed of how I look. I want to make lifestyle changes to address this issue, but I need to heal the broken skin first. What is a natural product that I can use on the broken skin to heal it without irritating the condition further? (Please no one tell me to see a doctor, I don’t have insurance or the funds). Thanks for any and all of your help

alexa barboe on October 12, 2015

I was diagnosed with PD one year ago with a case that flared up for about 6 months, and after 2, 30-day rounds of antibiotics and daily application of metronazidole it cleared up. My dermatologist (who I only started seeing for this— I had relatively problem-free skin before) told me to use the metronazidole daily for at least a year, which I have been. Uhg! I am not a fan of chemicals and would MUCH prefer using something natural— is there anything you recommend that I could swap out for this cream? Also, I don’t use much make-up, but when I do would prefer to use something that is also natural— I have used BareMinerals in the past, but have heard good things recently about Jane Iredale being safer/more gentle. Is there a make-up that you would recommend? Many thanks for your help!

Christine on October 08, 2015

I got diagnosed with PD sometime in my 30’s…maybe around 36. and I’m 47 now. I have it pretty much under control and have regular little flare ups but can make everything look better in about a day or so. Initially I got the antibiotic rounds, antibiotic creams and even a few cortisone (hydrocortisone?) shots but none of that seemed to really help. Through trial & error I got my PD under control with a gentle olive oil bar soap…..I wash my face every morning & night and even a few extra times during flare ups and then spot treat with salycilic acid (I use the Clean & Clear…for some reason it works better than the generic although the ingredients look identical). Anything drying is worse: so no tea tree oil products, benzoyl peroxide, or harsh astringents…. For flare ups I make sure so spot treat heavily with the salycylic acid gel.

My question is about an itching that I have near my eyes. I was told when I was first diagnosed that this could possible move toward my eyes and that it could be dangerous if it did. I did have an itchy patch near my right eye but when the dermatologist checked it out she said she could see nothing….even under magnification. This itching has never gone away and it still looks like nothing but it is intense and it is on both sides now. I guess I’m lucky that there is nothing to see but I worry about my vision. Sometimes it feels like the itching goes right up to the tear duct and it is constant and intense. Actually, I am surprised that there is not some kind of outward mark because I scratch constantly and very hard with my nail. Do you think this is PD near my eyes or something else?? I’m really worried since I’ve let it go on for so many years, but the ithing is maddening and definitely worse.

Also, I agree that the PD is hormonal (I’ve been hypothyroid for the last 12yrs) and am curious what will happen with the PD after menopause…fingers crossed.

Cynthia on September 26, 2015

I’m 19 and I’ve had a red rash, severely dry skin, occasionally little bumps, and sometimes dry skin on my eyelids and the sides of my eyes for about 6 months now. I’ve tried many different types of anti-fungal creams, eczema lotions, and cortizone 10 lotions and none of them seemed to work. I have two new creams i am about to start using to see which works best but after today i’m not sure that they will. Have you heard of or tried Metronidazole Gel or Ketoconazole Cream? I was doing some research on the gel and found that it is typically used for Rosacea, so I’ve been crying for at least an hour hoping it’s not that. That’s when i just typed in my symptoms and found your video. If you could please tell me your EXACT diet on how you help your PD and your thoughts on the gel/cream i have i would greatly appreciate it! I will make any changes in my diet and the soaps I’ve been if it will just make this go away. Thank you so much. <3

Cierra on September 21, 2015

I suffered from PD for almost 2 years, trying everything from RX to OTC treatments. Like many of you, I was extremely frustrated with the little results that came of these treatments and the contradicting and ever-changing diagnosis’ my doctors made. They would tell me they simply did not know how to treat it because PD is the perfect storm between eczema and acne. Great! Occasionally the RX drugs would temporarily “heal” my PD or minimize the outwardly signs, but like clockwork, it would also reappear and with vengeance! I do not think highly of oral antibiotics and would prefer to not take them, and the topical treatments left my PD more flaky, scaly and irritated. FINALLY, after almost 2 years I decided to take my ailment into my own hands and research natural ways to heal PD. By some miracle I stumbled upon Dr. Sarah’s blog on PD. At first, I felt the reviews were “too good to be true”. There are many claims to fame on the interwebs about ways to cure PD naturally, and as we all know, only about 2% of them ever work. Well, I took a chance on Sarah’s recommended Starter Kit (at this point I had nothing to lose) and not even a week after using it I was nearly in tears (of joy!). The starter kit moisturized my face, reduced the redness, and calmed the flames of my PD! I have been using the Starter Kit, the Black Clay soap, and the Clarification Serum (newly added to my arsenal) for 8 months now, and my skin is completely clear, without even one flare up of PD. (I also use the Spot treatment on occasion and that stuff is perfect for healing pimples before they ever truly become pimples :D). Sarah: thank you for taking a leap of faith and starting this wonderful company. I am so very grateful to have come across your article and tried your products. It is liberating to be free from the stress, embarrassment, and self-negating image I created as a result of my PD. I will be a life-long customer!

Kim Stoutenburg on August 21, 2015

I have had a few episodes of perioral dermatitis over last 10 years. In the past I have used doxycycline and topicals such as aczone and fanecia. This treatment had worked well, however I cannot tolerate those antibiotics anymore. I have severe gastrointestinal SE and headaches that keep me home from work! I just started taking evening primrose and switched to Jason’s toothpaste. I also purchased osmia sample kit- now I hardly cleanse my chin area and only put Rx topicals on affected areas. What exactly should I do to affected area with osmia products? Should I d c Rx topicals ?

Lexie on August 18, 2015

Help!!!! I’ve recently self diagnosed pd thanks to an Esthetician who performs laser treatments. My skin is so enflamed, and I am getting married in 19 days. I am on an oral antibiotic. It’s so dry and scaly and hurts. I am resisting putting anything on it and need to know what else can I do on such a limited amount of time.

Jarita on August 16, 2015

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