Perioral Dermatitis - Eczema, Meet Acne

By Sarah Villafranco
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 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 committment 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

I’m currently 14 years old and have had POD around my eyelids and bottom part of the skin under my eyes on and off since year 3. I have not used fluoride toothpaste for probably 3 years now and have been going back to using dermatological shampoo and body products. I used to use them, then when it cleared I stopped using them. I have found I need to go back.

I don’t want to use vinegar, thick creams as I have done before it has made it worse. I have the typical symptoms of redness and dry scaly skin and swelling, and have found that it flares up in extreme weather. Where I live in winter its dry and winds don’t make it any better but have found that after it has triggered and the weather has been nice it still doesn’t seem to go away.

As a girl in high school this is very stressful and the constant comments don’t make it any better. Could this be a potential factor of the disease? If so, I’m trying to feel better and make things easier on myself. I’m not usually a doubtful person and never have been but this is really getting me down.But Ill get through and so will everyone else I’m sure.

I don’t wear make up any more and don’t use harsh creams or chemicals on my face. But I don’t know what to use to keep my skin hydrated and healthy without making it worse even natural products sometimes don’t work. I know I shouldn’t put any moisturiser on my eyes but when they get so dry and start to hurt it’s very irritating. have been to the doctors previously and have given me steroid based creams used it once read about it and didn’t use it again. Have used about 20 difference creams ointments and oils. Previously it was very small and only came up in a small red dot but now its like red eye-shadow :/ Gotten worse. Any ideas? without being to harsh around my eyes?

Thanks so much for your info best regards
Erin :)

Erin on September 14, 2014

I have been going to a medi spa near my home town, which I love, for facials and she recently recommended to me some Vitamin C scrub pads to use when I come in from outdoors on my face after gardening or working outside. We live in SE Texas where it is extremely hot and muggy. She had noticed my pores were becoming much more clogged so she suggested I use the pads to cleanse after profusely sweating, which I do here in the south. After using several pads to remove the sweat and the day’s makeup I had been wearing from gardening I noticed the next morning little tiny whiteheads clustered all around my mouth and my nose and even under my eyes. My eyes were extremely swollen as well. Is this PD or is this something else??? I can’t find anything that fits my exact dilemma except PD. It will not go away and my face in those areas feels on fire and very irritated. The only thing I have different in my routine was use these new cleansing pads. I use organic based oils and serums on my face which has always been combination and irritable but these products have always helped me. I don’t know what to do and I am hoping to get maybe some suggestions or even some answers. I appreciate any help I can get! Thank you!

Meredith on September 11, 2014

My son who is 13 has Perioral Dermatitis. I feel so bad for him right now, it’s hard enough being a pubescent teen and now this. We first tried Elidel, from pediatrician and it did nothing. It continued to get worse. I took him to the dermatologist and she first prescribed metronidazole and it got worse. It now is spread around mouth, under his nose and some under his eyes. We were trying to stay away from anything systemic but he was now prescribed oracia (oral), acayna (topical) and finacea (topical). As I research these, they are mostly for rosacea skin conditions. I am hesitant to give the oral. I see many of your natural ideas above. Today I am going to get rid of fluoride toothpaste and sulfate shampoo. Since this seems to be primarily a female condition I wonder if it has to do with his hormones surging right now at 13yrs. If you have any other suggestions I would greatly appreciate it. Thank you

Lisa on September 11, 2014

HI,

My 10 year daughter has PD. It started about 9 months ago just a few red bumps around the nose then it would clear then come back then it started spreading. One Dr. prescribed a steroid cream and it made it worse and it spread further on the face and a few dots on the eye lids. So the next Dr. confirmed it is PD he prescribed 2 creams and an oral antibiotic. I’m not big on antibiotics but 9 months of this has been a lot on a 9/10 year old little girl. Its been two days and it is improving I’m hoping this will all settle it down and then I can continue on a more homeopathic approach if there are further outbreaks. What are you thoughts on Primrose Oil for a 10 year old girl. I’m going to check on the shampoos and other items for sulfates but I’m not sure I can cut the flouride as she already gets a lot of cavities.

susan on September 04, 2014

Just curious how many people have this that also have a thyroid disorder or autoimmune disorder?

kim on August 31, 2014

I am currently using neem oil after washing and using Osmia toner gel and moisturizer. I am cautiously saying I
do think it is helping. I only going to use it at night (it STINKS!)and I will post back in a week, maybe two,

jeannie on August 28, 2014

I have been suffering from PD for almost a year now, in addition to that I have moderate to severe acne. I have been on antibiotics for about 6 months. I can’t seem to find a skin care regimen that keeps the PD and acne at bay. Can you please advise? I am keeping away from fluoridated toothpaste and products with SLS. I am using the gentle Proactiv formula for my acne but it doesn’t seem to be helping much. I am scared to use anything with Benzoyl Peroxide in fear that it will agitate the PD. Any advice is appreciated. Thank you in advance!

Nhien on August 25, 2014

I can understand the frustration! I was lucky to have discovered Sarah a couple of years ago, and love the mud soap which takes FOREVER to use up :)! The only thing my dermatologist (one of the tops in NYC, creator of a major skin care line in dept. stores) could do was give topical treatments. One of these includes a blend of drugs including tacrolimus, apparently given orally for patients of organ transplants, to help avoid rejection. I am sometimes so desperate during a flare up (rare these days) I use these things, but it is worrisome, as I am sure they are very toxic. Sarah’s advice has been a life saver! In particular, I agree that one must change the toothpaste (which the derm also advised, avoiding flouride and SLS). Whole Foods and health food stores are a must in order to find some things….Eco Dent is a tooth powder that I started to use which is very pure, with very few ingredients and a delicious variety of flavors. I particularly like the anise. Not only did it help the POD significantly, my mother thought I’d just had my teeth whitened! I also like Giovanni hair products (not the purest, but at least free of dyes and SLS) at Whole Foods, or the unscented baby products there…that is until we have Osmia hair care! The last thing I’ll mention affecting my POD VERY significantly is FOOD. After eliminating grains and legumes, which for me were always hard to digest, and focusing on mainly vegetables, organic meats/fish, a bit of fruit and nuts with very little dairy (homemade cashew milk is great!) I noticed dramatic improvements – quickly. So my thought is this: perhaps when a food does not agree with us, it shows up as various skin conditions. It’s perhaps worth eliminating some common food allergens for a while to see if this helps. Good Luck everyone!

daphne on August 22, 2014

After doing much research of my own, I am almost certain I have PD. I went to my dermatoligist about 2 months ago with a red rash just around corners of my nose. Had tried antibiotic creams on my own without any results. The doctor called it some type dermatitis but not PD and gave me a steroid cream and an antifungal. He told me to rotate the two every 2 weeks. Needless to say, this condition has become horrible! The steroid cream controlled it for 2 weeks at a time but immediately after stopping it, the rash spread! It is now around my mouth, nose, and chin. I also have two different spots around the corner of my eye. In my research, I read this disease affects women of child bearing age. Ironically, I’m 60! Have you ever heard of someone my age having PD? I have another appt. with my dermatoligist tomorrow. I’m going to ask if he thinks this may be what I have and will follow his instructions, unless, he perscribes another steroid! I will try omitting most of the products you’ve mentioned in this article. Praying something works! I’ve never had anything this persistent and aggravating!

Fran Cobb on August 19, 2014

I have been suffering with troublesome skin since age 14. I’m now 33 and I am STILL breaking out. I have tried so many things, some of which helped for a while (Proactiv, two rounds of Accutane, and oral contraceptives) and some that didn’t help at all (Retin-A, oral and topical antibiotics, salicylic acid, light therapy). My new dermatologist recently diagnosed me with PD and prescribed doxycycline and Elidel cream. My breakouts have always occurred around my mouth and chin and have always been the small, inflamed pustules. Occasionally I will just get one or two, but lately I have been getting clusters of 10-15 all in that area. I have never had cystic acne and I hardly ever break out on my cheeks or forehead. I am very interested in holistic medicine and taking a more natural and integrative approach. I recently switched out all of my products for natural products and I have cut out dairy, gluten, and processed foods. I am nervous to try the Elidel because I am not 100% sure that what I have is PD. I am willing to try anything right now because I am getting married November 1st and am SOOO afraid that my skin will be terrible on my wedding day.
Thank you so much for any advice!
Annie

Annie on August 19, 2014

I have PD around my eyes. It is miserable. I wake up with swollen eyes every morning. It gets better for a few days and then worse again. I have been on antibiotics for about a month now and I dont think they are helping one bit. Any suggestions? I can’t tolerate anything around my eyes.

Nicole on August 17, 2014

Is it possible for PD to spread to your nose? I’ve been to the doctor numerous times and they said it could possible be PD. It started about 5 months ago when I over exfoliated my face and woke up with red puss filled bumps on my chin. As the days progressed it spread around my lip. I have been on 3 different antibiotics and plenty of creams. At one point it stared to calm down there were still a couple of patches left. They almost looked like irritated black heads. Then about a month ago I started up on another cream to see if I could dry those few patches up. It only made my whole chin and around my nose extremely dry ! I thought it would be okay so I put makeup on it and went to the beach the next day. By the the next morning my chin had completely flared up again ! Does this sound like PD ? Or maybe I’m being misdiagnosed.

Lindsey on August 15, 2014

Hi Dr. Sara: I came across your website last Fall after being diagnosed with PD after using steroid creams on my face (OOPS) following a hives outbreak of unknown origin. I can’t thank you enough – after eliminating fluoride based toothpaste, sodium laureth sulfate products AND using black clay soap my PD has been virtually eliminated. After the hives outbreak I went through a series of patch tests and tested positive for EVERY shampoo, even those from Whole Foods without sodium laureth sulfate (or a host of other horrible sounding things). I haven’t been able to pinpoint what the problem is and continued using the whole foods shampoos as they weren’t causing me an issue. A couple weeks ago I stupidly tried a “stress relief” shampoo from bath & body works with Eucalyptus and Spearmint. OMG caused a horrible hives outbreak. Back on the prednisone (not ideal obviously but as it continued to spread and worsen I felt I had no choice). My allergist recommended some special order shampoos made for sensitive skin but even THEY have sodium laureth sulfate!!! REALLY? So what’s a girl to do? I have to wash my hair! Can you recommend anything? Oh, and have you guys thought about creating a hair products line?? :-)
Sincerely and with appreciation.
Lori

LORI on August 07, 2014

wow this is so informative! i’ve been battling on and off PD since 2011. it’s been really bad since last summer (after birth of my 4th baby and as i’m closer to 40)—and especially worse since this past january. so i wouldn’t be surprised by hormonal component from my past almost 8 years of pregnancy and nursing! i’m going to try these products and the oil supplement. i’ve already changed my toothpaste awhile back and had doctors give me on and off use of steroid cream, which help briefly and it all comes back and worse! also taken gluten and now trying to remove dairy from diet as well to see if that helps some?? but it’s so frustrating! what do you recommend for hair care?? i try to buy organic more real ingredients skincare/tolietries typically but i know even some organic still have sodium laurel sulfates in them. is there a brand you recommend since there are none in your store?

Erica on August 05, 2014

Hi Naudia and Michelle,

For Michelle: Different treatments seems to work for different people when it comes to perioral dermatitis. That’s part of what makes it so tricky! In my personal experience, any oil applied directly to the irritated area tends to make it flake more. If it seems to help your situation, however, there is absolutely no reason not to use it every day, though I would probably recommend using it sparingly – everything in moderation.

And Naudia, It’s pretty frustrating, I know. I have not heard of poison ivy and Mederma being used to clear PD. Have you eliminated fluoride toothpaste? Also, evening primrose supplements can be helpful (not for use during pregnancy). As for makeup, all of it seems to irritate my skin, so I don’t wear it! But Dr. Hauschka just came out with a line, and their products are usually extremely pure and non-toxic, so you may want to check them out. Feel free to email me on the website if you have further questions. And, remember to consider ways in which stress may be affecting your PD, and work to reduce stress to the best of your ability.

Best, Jessica

Jessica on July 09, 2014

I’ve tried everything it seems, oils, ACV, yogurt masks, probiotics, SLS free, and gluten free. I’m now a vegan and don’t eat preservatives and additives, nothing seems to help! I’ve even done the oral and topical antibiotics! Have you heard of poison ivy spray or Mederma being used to clear PD? Also what kind of make up, if any, do you recommend? I don’t want to anger it more! Thanks!

Naudia on July 09, 2014

Can you tell me if Neem oil is good for Perioral Dermatitis, and can I use it daily?

Thanks,
Michelle

Michelle on July 09, 2014

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