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

You’ve provided such excellent information here, thank you! I’ve had luck keeping my PD mostly at bay, but I had to stop using sunscreen, and at this point I’m afraid of most products. What do you sugget/use for daily sun protection?

Susan G on November 13, 2014

I had PD for 2 years. Took multiple rounds of antibiotics. Tried every suggestion out there from the internet. What finally worked was going on an elimination diet suggested by a naturopath: No gluten, dairy, wheat, soy, eggs, nuts, or refined sugar. Well, what do you know, the scourge was gone within 9 days and only returns when eat gluten or dairy. Mainstream dermatologists refuse to consider the role of diet. Shameful.

Jen on November 08, 2014

I have been suffering from PD off and on for a couple years now. In the past weeks it has come back with a vengeance . I have been thinking about did I change anything or add any product to my regime. Reading your article made a light bulb come on when I thought about how I started using a new toothpaste a couple of weeks ago!! Needless to say it was not fluoride free and is in the trash. Going to follow your advice and see what happens!! Thank you for this!! At least I’m not alone in my skin struggle !!

Caroline on November 04, 2014

And do you use sunscreen? My skin is white and sensitive and I have freckles all over my face and arms, so I must protect my skin from the sun. Is it bad for perioral dermatitis to apply sunscreen or is there a product you recommend?

Natalia on November 02, 2014

@Natalia So sorry for your struggles. Be sure to make all the lifestyle changes recommended here, and in the FAQ blog post as well. As for products, you may order from our site – we ship to Mexico. But I always recommend ordering sample sizes first – you never know how your skin will react, even if most people have good things to say about the products, it’s different for every person. Hope that helps, and best of luck to you! Sarah.

Sarah Villafranco, MD on October 30, 2014

Hi, thank you for this site… it is really useful. I’ve had this condición for almost a year now. I was first diagnosed with atopical dermatitis, so I used cortisone creams and then cortisone and metrodinazole creams (Lenicort 1% and quadriderm). I also took vitamin A tablets and doxicicline for 4 weeks. I still have my bumps and it is worse… It looks like acne and I even have comodones, I even started to have some comodones in other parts of my face, but they are isolated and small. I am from Colombia and I live in Mexico. I am really interested in your products based on your experience. I would like to know if I can get tose here in México or if it is possible to send them from USA. Thanks again!!

Natalia on October 29, 2014

Hi. My PD was terrible for years, and much worse during spring and autumn. Definitely on season changes. However it has now been absent for over 12 months since removing all wheat products from my diet. I had been having the antibiotics for 6 weeks at a time several times a year. Since removing white potato, rice and wheat from my diet I am much healthier and totally free from PD. Also heartburn! Ya. Maybe this could help others. Cheers.

Debbie on October 22, 2014

@Cara – Did you ever try the Active Gel Toner? It might be worth ordering a sample size of that to see if it settles things down at all. Have you made all the other changes recommended above, like eliminating fluoride and supplementing with Evening Primrose Oil? Those can help diminish redness as well. And be sure to “handle” your skin gently – PD skin is reactive skin, so scrubbing it or touching it excessively can make redness worse. Hope that helps, and best of luck. Sarah.

Sarah Villafranco, MD on October 21, 2014

I had a terrible acute PD flare up in May. It’s since cleared up (with the help of your soap), but the skin remains red (almost like scarred under the surface) where the flare up was. Can any of your products help reduce this redness? Or, do you recommend anything else that might help?

Cara on October 21, 2014

@cathy I have lots of women over 60 using the Black Clay Facial Soap and loving it! But, each person’s skin is so different – you should order a sample first and see how it goes. That way you don’t spend as much up front, and our soap samples last long enough to get a good sense of how your skin will respond.

@kristin and @laura I don’t wear foundation, so I can’t answer this with any personal experience! I love Alima Pure and W3ll People makeup lines. I’ve used Alima’s eye makeup and W3ll People’s Bio-Brightening powder, both of which were great. I’m sorry I don’t have better intel on the subject. I do know that bismuth makes my PD symptoms appear, as well as beeswax based products. Hope that helps, and maybe some other PD peeps can chime in about what makeup has worked for them!

@kellie and @julia So glad to know you have found a touch of relief with the products. Nothing could make us happier!

Sarah Villafranco, MD on October 20, 2014

Your site is so helpful, thank you! I’m 59 and my skin has always been sensitive with a tendency to be dry. Breakouts have always responded to mild, not acne treatment. Recently I added an herbalized oil to my moisturizing regimen and noticed a little rash under one eyebrow but eventually it went away. Then I had a bad cold/flu and took lots of Yin Chaio and since then I seem to have POD for the first time ever! I guess it was “a perfect storm” and I think/hope it can be reversed. I never use products with sodium laureate sulfate or fluoride, have cut back on the non-creamy exfoliating cleanser I always use and have gone back to the (limited) moisturizer and non-moisturizing mineral foundation that have worked for me for years. I’d like to start using the Osmia black soap to start with for the POD (and I’ve been looking for a new cleanser anyway) but it doesn’t say it’s for dry aging skin. Will it be too drying for me even though it’ll help the POD? If so, should I just use it anyway until the POD goes away and then switch to the rose clay soap?
Best, Cathy

Cathy on October 15, 2014

My biggest concern is what foundation to wear.
Often times my PD will clear up, and as soon as I start wearing foundation it is back again.
Do you have any recommendations?

Kristin on October 08, 2014

…so I got my soap in the mail last week. I have been suffering on and off with PD for the last six months. I did not go to my dermatologist, I really wanted to naturally try and figure out a solution vs. drugs but would use drugs as my last hope if the soap did not work. I used it faithfully day and night along with some coconut oil for added moisture in place of my other moisturizers (in fear that an ingredient in the moisturizer was causing it) and after about five days I am seeing my PD outbreak starting to disappear. The redness is diminishing and the dry flakiness is subsiding, along with the burning due to sensitivity I was experiencing. Very happy and satisfied with this product to say the least.

Thank you for this great soap!

Kellie Oriee on September 25, 2014

I am wondering what you would suggest for sunscreen? and do i put it on top of the toner/lotion? also, i have tried the non flouride toothpaste and my teeth get SO sensitive i can’t stand it..i have an enamel problem. Any thoughts on that? I have cut out SLS hair care products but wondering about my make up? thanks. Laura

laura on September 25, 2014

Last year I had PD for about 8 weeks, I had a very severe case, with red inflammation, blisters and flakes around my mouth, nose, eyes and forehead. I looked unsightly and tried everything from yogurt masks (which made it feel better, but didn’t clear anything), apple cider vinegar, coconut oil, reiki, acupuncture and finally had to go on an oral antibiotic as well as antibiotic cream. At the same time, I ordered the PD starter kit from Osmia, my face was so dry and uncomfortable and the Osmia products were wonderful. I’m still using Osmia products, since I am still avoiding any face cleansers or creams with SLS and other additives.

Julia on September 22, 2014

I have had perioral dermatitis off and on for about 10 years. It is such a frustrating and humiliating issue. I feel so confused about my body and its inability to heal from this condition. Long ago I removed fluoride, and SLS. I have also been sugar-free, preservative-free, gluten free, dairy free, eating lots of organic fruits and vegetables, coconut oil, olive oil, avocado oil and wild fish and organic grass fed beef…drinking lots of water. My skin doesn’t seem to care what I do. I feel very good health wise. I look terrible. And I am so tired of this. I wonder if antibiotics would help, but I am afraid to throw off the health of my gut and my body. I have ordered the 3 skin care products you recommend for perioral dermatitis. Is there anything else I can or should be doing? Thanks,
Alicia

Alicia on September 18, 2014

Hi there,
I have not long turned 20 and I am certain I have PD. I am currently studying in spain for my year abroad so don’t have the support of my family at this time which I feel is making it harder. I went to see a spanish doctor and she completely ignored my problem and didn’t give me anything or even offer advice. I am returning this week to see a different doctor so hopefully she is more understanding. I have suffered from acne for the last 8 years and never quite managed to get it totally under control. However i used a lot of clinique products rigorously to help clear my skin (which im sure have steroids in the gel) and i think this is what has triggered it. I have stopped using my clinique products and the rash is still not leaving my face, furthermore because i have spot problems as well as PB i am starting to notice spots returning to my face and I think the acne is coming back. I feel so lost and depressed constantly having bad skin and would appreciate any advice you could give me.

Thanks
Jennifer

Jennifer on September 17, 2014

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

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