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 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!

 

Related Products:



Comments

@Jen – Check out our PD FAQ blog post for more info, but here are my best makeup tips (I don’t wear foundation, so I can’t attest personally to any of these – sorry!) “Ideally, you should not use any makeup while your skin is angry and red. Almost all foundation and pressed powder will irritate it further. But, if you have an important occasion and need to use something, certain brands may upset things less. W3LL People is an incredible brand, founded by incredible people – I have tried a few of their products and just love them. For eyes and lips, Kjaer-Weiss is a boutique brand with a great reputation, as are Vapour Organic Beauty and RMS Beauty. Ingredients to avoid in makeup over the affected skin are bismuth (in many mineral foundations and powders), talc, parabens, petroleum, and possibly beeswax (it forms a heavy layer on the skin and can be too occlusive).” Good luck, and I hope your skin settles down soon. -Sarah.

Sarah Villafranco, MD on March 23, 2015

Hi Sarah,
I was wondering if you could recommend makeup for someone suffering with PD. Mine is so bad that I HAVE to use something to cover it up when I go out in public or I feel like a horrible monster, but I don’t want to further exacerbate my PD. Any reccomendations would be greatly appreciated! Thanks so much.

Jen on March 22, 2015

@Lori – Totally understand about feeling unattractive – it’s very hard to remember that your beauty is more than skin deep when your skin is misbehaving! PD can affect the lips, but sometimes you may be dealing with a second problem there. I hope things have improved by now, but eliminating SLS and fluoride in all personal care products (double check toothpaste for SLS, not just fluoride) is a huge step. Please feel free to email us on the site if things don’t settle down soon. Best, Sarah.

@Melody – It’s so unfair when your skin switches from zero-maintenance to high-maintenance – ARGH! To answer your questions, both stress and essential oils can exacerbate PD. We use VERY small percentages of EOs in the formulas we recommend for PD (less than half a percent). But, occasionally, when my skin is super angry (rarely, thank goodness), I try to use unscented everything. As for petroleum jelly, I don’t love it on the skin of the face, where I think it really interferes with the function of the skin. That said, and petroleum-related issues aside, I do think it can help the skin heal when all else fails and the skin is raw and angry and red. For daily use on mild symptoms, thought, I think it could be exacerbating things. As for a mild cream suggestion, you can try ordering a sample of our Purely Simple Face Cream on our site to see if it works for your skin. Cetaphil doesn’t work for a lot of PD patients – not sure why so many docs keep recommending it. Healing wishes your way – Sarah.

Sarah Villafranco, MD on March 22, 2015

@Shannon – Thank you for sharing your experience. It sounds like you are actively researching your own skin, and making great, healing choices for yourself. Well done! – Sarah.

@Lisa – Life with a transplant is even more complicated than regular old life, which is pretty darn complicated! You seem to be taking amazing care of yourself, and that “new” kidney is so grateful! As for how long it might take for your PD to clear, I usually advise people that it may always lurk around the corner, and can come cropping back up with stress or too much coffee or with any other trigger specific to your specific case. So, you are doing all the right things, and your most powerful weapon now is patience. Oh, and I have found that coconut oil makes my PD flare – maybe it’s worth an experiment in eliminating it for a bit? Best – Sarah.

Sarah Villafranco, MD on March 22, 2015

Hello, I just recently purchased the black clay facial soap which I like and feel that’s it’s working. I’ve only been using it for a week and just curious how long it takes before my PD is completely clear. I had a kidney transplant 13 years ago and also have rheumatoid arthritis. I’m off all my medicine for RA but can’t come off the anti rejection medicine for my kidney. I tried the primrose oil supplements but I had a reaction from taking them. I have to be careful with supplements because of my kidney and the medicine I take. I take quite a bit of supplements from USANA, eat very healthy, removed sls and fluoride as well. I also use coconut oil, but can the coconut oil be making my PD worse.

Lisa Fredrickson on March 20, 2015

I am 36 and have battled PD since around 30, however I haven’t had an episode in a while, thanks to many mortifying outbreaks and the desperate research for anything to get rid of it! Mine started from using nasal sprays full of steroids, then putting hydrocortisone on those dry patches. My surest trigger was stress (especially emotional) and over exfoliating-this was a hard lesson for me since I am extremely dry and flaky and as a result have acne breakouts from it. Using too much product and switching them too often exacerbated it. Another factor for me was season changes-onset of spring in New England especially would bring a flare up. It is such a trial and error figuring out what works and what makes it worse-and you are so right, Sarah, that it is a temperamental condition that seems to need to go through all the stages in order to clear-and I have found that to be true even while helping it along with something that does work. The stress I felt just over having such ugly chaos on my face (I’m a makeup artist!) seemed to feed it reason to stick around longer-such a cycle!
Some things that I’ve found helpful are: switching to fluoride free toothpaste, diluted ACV toner, plain yogurt masks, bentonite clay masks (sometimes mixed with ACV), probiotic supplement, fragrance free everything, colloidal silver, aloe straight from my plant (a godsend is Natures Path Silver Wings silver aloe tea tree gel-only 3 ingredients!!-must get it for so many uses!!) One thing PD seems to need is to dry out in order to heal, which is so hard not to remove those flakes (trust me, it only prolongs it and creates little crusty scabs!) I try to eliminate sulfates, parabens and fragrance, which seem to aggravate it, and I have become quite a beauty DIYer out of necessity to control ingredients, as I seem to have become sensitive to many things in my 30’s along with it.
My sister introduced me to Osmia (she suffers too) and I loved the samples of black clay soap and rose clay soap-they do last a lot longer than they look like they would if you put them on the soap saver away from the sink) Currently I’m using a silver facial soap and straight aloe leaf after, ACV toner in evening and alternating clay and yogurt masks depending on where I’m at in my cycle. A final suggestion is watch what you use on your hands also, especially creams, as it will transfer to your face-also change your pillow case often! Good luck in your own quests :)

Shannon on March 17, 2015

@Stacy – I have had pretty good luck with Desert Essence unscented shampoo and conditioner. Check out the PD FAQ blog post for other ideas! Good luck, and great job taking care of yourself. -SV

Sarah Villafranco, MD on March 08, 2015

So I have had PD for the past 6 months and tried it all like most have written on this blog. I recently ran into a friend who told me about the Black Clay Facial Soap. In reading this post on PD which is fantastic, I have learned more about SLS. THANK YOU!!! I recently did allergy testing on my back to my facial and hair products and guess what showed up?!?! The shampoo and body soap that I use and the both contain SLS! So, now I have been on a hunt for a shampoo and conditioner that would be great and I am at a loss. Does anyone have any suggestions? Thank you!

Stacy on March 05, 2015

I just found your website and ordered the Black Clay soap. I’m 45 and have only been dealing with PD for about three years. I went to a dermatologist who gave me doxycycline and antiboitics. They worked at first but as soon as I stopped taking them it came right back. It seems to come and go with no rhyme or reason and has recently gotten worse. I am wondering if it can affect the skin of the lips as well. I thought I was just getting chapped lips from the cold weather but its lasting long after the weather changed. I have cut back on how often I wear makeup, stopped using the wrinkle cream and and changed shampoos. Next up planning to drop the fluoride toothpaste and start using your Black Clay soap. Feeling rather unattractive these days.

Lori on March 04, 2015

Thank you for the great post! I have developed a somewhat mild, but persistent case of PD. I have not seen a dermatologist yet, but have been seeing fairly significant improvement after discontinuing the use of steroid cream I originally used to treat some eczema. But I am still getting small flare ups. A few questions –
1) can essential oils cause PD? I don’t use them directly on my face, but I do like to apply occasionally to neck area or in baths.
2) Can increased stress cause flare-ups of PD?
2) I have used vaseline for years (about 20) on my face as a moisturizer, and have always had beautiful, pimple free skin. I also occasionally used jojoba oil in an attempt to move away from the petroleum based product, but jojoba does not provide enough moisture to my skin and I end up getting dry spots on my face. I have extremely dry, extremely sensitive skin and have tried multiple moisturizers (organic, expensive, oil-based, plant-based, etc) and always return to good old vaseline. However, I’ve never had a problem like PD before, and I’m concerned vaseline will continue the mild symptoms I’m having (I have not been putting in on my chin/nose area, but have been using vaseline on my cheeks and forehead to maintain the rest of my face). My question is: do you have any other suggestions for very mild moisturizers (cetaphil doesn’t work!) AND do I need to try and discontinue the vaseline?

Thank you for the great info and your time and help!

Melody on March 03, 2015

@Susan – have you eliminated all SLS and fluoride, from toothpaste to laundry detergent? With little babas, I am especially hesitant to start antibiotic therapy until you have exhausted all other options. I would probably consider an elimination diet – gluten and dairy to start – and see if the symptoms abate. You could order samples of the Black Clay Facial Soap and Purely Simple Face Cream on our site – it should be enough to give you a sense of whether they might help. I have seen them help several children, but I know they are expensive products for kids! I think one person told me that California Baby makes a calendula cream that helped a bit, in case you want to research that (only one report, but probably still worth a try). Hope that helps. Email us on the site if you have any other questions! Best, Sarah.

Sarah Villafranco, MD on March 02, 2015

Good Afternoon, I have a 16mth old that has been diagnosed the same condition and after using a steroid type cream we have now been advised to go on a 4 weeks antibiotic course! I am unsure of this. Do you have any advise for little ones?
We have always tried keeping to natural based products. There is a history of eczema in the family and she did have a bad case of it on her arms which has cleared months ago.
Not sure what to do.
Thanks
Susan

Susan Kruk on February 27, 2015

@Sophie – I hope your skin continues to improve, and I hope we will end up in the Netherlands before long! Be well, Sarah.

@Joy – safest to eliminate all sulfates, but sodium laureth sulfate is the biggest offender for most people, so it should be the first to go. Hope that helps – Sarah.

@Kristiina – so sorry for your long struggle with the condition. I think lots of people work to manage it over the course of many years, unfortunately. I understand about the teeth – it’s a tough choice! Be sure you are doing all you can to manage stress, eat a clean diet, and treat your skin very gently – remember that it’s not doing this to make you crazy! Please feel free to email us on the site with any specific questions. Best, Sarah.

@Nonto – you can email us on the site if you’d like to place an order. We don’t ship there from our website, though. Be sure you read the FAQ blog post about PD on our site, and double check that you’ve made all the changes (toothpaste, diet, etc.) you can to support your skin. Also, remember not to change your routine too often – when your skin is upset, it needs consistency and patience. Best of luck, Sarah.

@Lauren – I know how frustrating that can be – if you fix one thing the other shows up! If your face is reacting to the products, just use one at a time, and introduce the others slowly. You need to move slowly with skin that is irritated, and there is always a chance that you have an allergy to one of the ingredients. Also, the Spot Treatment is really helpful to some of our combined PD/Acne sufferers. Sending support and hopes for calmer skin soon – Sarah.

@Carla – We sent you an email, but in case you’re checking the blog, our advice was to use only one product at a time until your skin adjusts. Switching your routine to all three products may have been too much for your skin to process. Also, there is always a chance, even with natural products, that you could have an allergy to an ingredient. So, use the soap for a week, and if your skin adjusts, add the cream for a week. If your skin adjusts, you can add the toner. Apply sparingly to affected areas. If it does not adjust to one of the products, it may be that your skin does not agree with that product, but if you introduce them one at a time, at least you will know which one it is. Hope that helps, and please email us on the site if you have any further questions. Best, Sarah.

Sarah Villafranco, MD on February 27, 2015

Hello,
I just started using Osmia soothing starter kit last night. I had Perioral Dermatitis but combatted it with Cerave regular pharmacy brand products. I have not had a break out in months, however after two application of the black soap, serum and cream I have bumps around my mouth that look a lot like PD. Why would this happen? I thought the product were suppose to keep PD from coming back, NOT MAKE IT RESURFACE. I am so confused and frustrated. Should I stop using the products? They seem to be creating PD; I mean, I have not had any bumps in motnhs , now all of the sudden ,after two uses of the soothing kit, I am a bumpy mess once again, just in time for the weekend :(
Please advise. I am worrying here.

Carla on February 27, 2015

I was diagnosed with PD this year and I ordered your products and love the soap! However, I am wondering, is the toner and lotion one of those where it gets worse before it gets better? Both cause my entire face to break out so I was just wondering if I should keep using them because it will get better or it that means my face doesn’t agree with them. I’m struggling with controlling my PD and acne. It seems that when one is under control the other flares up.

Lauren Miller on February 24, 2015

Hi, Im from South Africa and have been suffering with this irritating condiction for years. There is nothing I havent tried, from acne treatment to natural products. I just do not know what to do anymore. Hence, I would like to know if you ship your products to South Africa, I would really love to try these products and tell me does the cream have sunscreen?

Thanks.

Nonto on February 23, 2015

I have suffered with PD since I was 12 years old. It was a year or two before my mother took me to see a dermatologist. I have been on tetracycline and erythromycin as well as other steroid creams. The tetracycline never worked, but the erythromycin worked after being on it continuously for 3 or more months at a time. I am now 38 and the PD comes and goes for no rhyme or reason that I can tell. I have been resistant to eliminating fluoride toothpaste because I have very sensitive teeth, but I am so tired of this whole thing, I am ready to do whatever I can. I have found some relief with applying double bergamot earl grey tea to my break out areas, which seems to relieve the redness, but only seems to help initially. I have been trying diluted apple cider vinegar for a couple days, but I’m not sure if it is helping or harming at this point. I have some calendula ointment that my sister, who makes her own natural products gave me, but it doesn’t seem to be doing much. The best result I have had from any cream or ointment has been from Ozonol, believe it or not! It doesn’t seem to agravate it, and it used to heal it, but not anymore. I would like to try your products as I know there is nothing available where I live. Hope it helps!

Kristiina Smith on February 22, 2015

Hello, maybe a stupid question, I understand to avoid/eliminate sodium laureth sulfate, but what about all other sulfates in products? Are they OK or best to eliminate all sulfates? Thank you!

Jay on February 17, 2015

I got PD at an early age (21) and after ten years, it’s still there… After the zillionth antibiotics prescription, I thought it was time to see whether there was anything I could do about it myself without using antibiotics. Turns out: there is! Thanks for your advice. Following it has definitely reduced my symptoms. I’ve switched to all-natural skincare as well. After a while, I noticed that on most days it’s not that visible anymore. Too bad your products are not for sale in the Netherlands….

Sophie on February 11, 2015

@Kristen – Very glad you found something that works for you. I have heard a few people say the California Baby Calendula cream helped – it does not help me, but every case is unique. I would not think that petroleum jelly would help many people with PD – it’s quite occlusive, and irritates most PD skin, so you are a lucky outlier in that way! Thanks for sharing. – Sarah.

Sarah Villafranco, MD on February 07, 2015

I have been battling pd off and on for a few years. I tried every treatment under the sun from vinegar and various creams to eliminating sugar and dairy from my diet. About 6 months ago I finally found something that works for me. At the first sign of breakout, I apply California Baby calendula cream to my face at night. It is not greasy like other creams I have tried. (Available in the baby section at target) I then apply a layer of eucerin Aquaphor healing ointment over the affected area. By the time I wake up in the morning the inflammation is 90 percent gone.

Kristen on February 05, 2015

I was diagnosed with chronic PD and it has been a huge battery drainer for me. Most triggers don’t apply to me so the biggest black cloud has been trying to find out what makes it start. I had relative success with apple cider vinegar and clay masks but I still have to wait a few days for my skin to get better. Now that I know oil-based products won’t help the skin heal, I’ll be changing my skincare. Hopefully I can get my PD under control, if not banished.

Ari on January 31, 2015

@Oksana – I probably would not recommend the EPO for your son. He is entering a stage of development that relies on his body’s natural hormone balance, and I think the estrogenic effect of EPO could interfere with that. Make sure you’ve addressed all the other things, though, like diet, SLS, and fluoride. Even check your laundry detergent and toothpaste for SLS – it’s often hiding there. Good luck to you both.

@Lee – Great job researching your triggers and being an advocate for your own health. It’s wonderful that you have had such success with your elimination diet!

@Barbara – So good to hear about the liquid CS. I have not tried that personally, so I’ll keep it in mind if my skin ever decides to freak out again! Thanks for sharing your experience here. :)

Sarah Villafranco, MD on January 30, 2015

I have been suffering with Perioral Dermatitis for 6 months. It started on my chin, moved up to the folds around my nose then up to my upper and lower eyelids. It was very itchy and burning and generally uncomfortable. My dermatologist wanted to do oral antibiotics, which I refused. Instead I removed all sources of sodium laurel sulfate, (laundry detergent, soap, shampoo and toothpaste) and it improved everywhere except my eyelids. I think it is because I have to put steriod drops into my eyes everday. I also have mast cell activation syndrome. A couple of days ago I saw my mast cell specialist and she gave me a prescition for cromolyn sodium liquid, a mast cell stablizer, and told me to put it on my PD. It stopped itching in about an hour and It drastically improved overnight. There is no more itching or burning and it has begun to heal in just a couple of days. So it is definitely a mast cell activation for me.

barbara on January 29, 2015

Hi,

I don’t have your particular condition, however for most of my life I suffered from chronic rosacea on the nose and across my cheeks. I was on antibiotics on and off for over 20 years which have in turn affected my health terribly. However, two years ago I came across a skin specialist that told me to remove from my diet, yoghurt, cheese, chocolate, tea, coffee and alcohol. I removed all these things from my diet and within only two months my skin cleared “without” antibiotics. I have been free of skin problems for two years now which is a miracle for me. I have also gone gluten free for other health reasons. I have tried introducing some of the above foods but they are definite triggers so I avoid them altogether now.

I would recommend anyone with rosacea to try eliminating these food triggers.

Getting healthy without drugs is the way to go if at all possible.

Lee

Lee on January 29, 2015

Leave a comment

comments have to be approved before showing up.