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!

 

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Comments

@leener – Yes, the sample kit is small, but priced so that you can try it without having to spend a ton of money up front. The products cost us so much to make, and we do it all by hand with beautiful natural ingredients. If finances are the main concern, you might look into drugstore brands, rather than an artisanal line like Osmia. One sample kit should last 4-7 days, depending on how often you use it and how much you use – the soap can last a couple weeks if you keep it dry between uses. Hope that helps! Best to you – Sarah.

Sarah Villafranco, MD on January 22, 2015

@nina Most makeup irritates my skin, but I am super sensitive. I know that certain mineral makeup lines contain talc and bismuth, both of which make my PD flare up. Double check your toothpaste for SLS, not just fluoride. And be sure to change to sulfate-free shampoos as well. As for mascara, I use it occasionally without negative effects – either Tarte or Alima Pure. Hope things settle down soon – Sarah.

Sarah Villafranco, MD on January 22, 2015

@kristi – I don’t believe it’s a contagious condition, though sometimes people in the same household can develop similar symptoms. Usually, it’s because of a shared environmental sensitivity. Nobody really knows whether organisms play a role in PD. Some theorize that demodex mites are part of the problem, while others claim that a gut flora imbalance contributes. Both could be true or untrue, depending on each individual. But I wouldn’t worry about it spreading through contact. As for garlic, it makes me a burpy, miserable mess, so I can’t answer that one!! Best of luck, Sarah.

Sarah Villafranco, MD on January 22, 2015

@ashley I would try to resist exfoliating, but sometimes I will use a soft, wet washcloth to wipe my face with warm water if my skin starts to show some flakes. Then I moisturize immediately afterwards. And you can spray some Avene mineral water on your skin a few times a day. Hope things are improving! Sending hope and healing – Sarah.

Sarah Villafranco, MD on January 22, 2015

The perioral kit seems super expensive and super small. Can someone please tell me how long a kit has lasted for them? Thank you!

leener on January 17, 2015

Hello. I have had PD for more than 6 mo :( I have been to 2 primary MD and 2 dermatologist (because I moved states). I am now on metrogel antibiotics BID and protopic for non steroidal anti inflammatory affects. I wash my face with a mild face soap. I will take your advice to change my toothpaste. I have been using organic non sulfa/fragrance/parabins. My question is is it still of to use light mineral make up and mascara? I have stopped make up for 2 weeks and the rash still comes up. Thank you.

Nina on January 16, 2015

I was just diagnosed with PD and tying to research about it. Can’t find if it is contagious or if it can actually cured. Dermatologist prescribed an antibiotic and a facial cream but I’m more natural so looking for those type of treatments. I’m just wondering if anyone has tried swallowing garlic for part of their treatment?

Kristi on January 08, 2015

Thank you for this great post! POD is such a nightmare. I’ve been dealing with it off and on for four months. The most recent outbreak shocked my dermatologist. I didn’t realize that one of my cystic acne gels contained a steroid – great…. I saw my doctor on a Monday and she prescribed Metrogel and Minocycline and to stop using the steroid. The rebound was horrific. I saw her again on Wednesday and she admitted it was the worst rebound she had ever seen. That’s comforting! I’ve since followed through with her protocol (after a hives reaction to Minocycline – now taking Clindamycine) but have added OO black clay soap. The gel toner should be arriving at my home any minute! My question is regarding the dry flaky skin that occurs after the bump rash has cleared. What’s the safest way to deal with it? It’s so tempting to exfoliate but I’m trying to resist the urge. Suggestions?

Ashley on January 07, 2015

@Kristina – I take 2 of the Barlean’s brand EPO daily. That’s a dose of 2600 mg per day. I like their brand because most EPO is 500 mg per capsule, and you have to take more pills! Remember, if you are pregnant, trying to get pregnant, or nursing, talk to your health care provider before starting EPO, especially at a relative high dose. Good luck, and thanks for sharing your experience –
Sarah.

Sarah Villafranco, MD on January 05, 2015

@Lexie, @Lewis, and @Alissa – So sorry to hear that your kiddos are struggling with PD. There is not much worse as a parent than watching your child be frustrated by something like this. My daughter gets a touch of it from time to time, and it seems to resolve with a few days of more attentive skin care. She uses the Black Clay Facial Soap and the Purely Simple Face Cream – she’s my kid, so Osmia products seem like a natural choice for her, and they do help, in her case.
It sounds like you are each doing an amazing job researching the condition and being proactive about making as many changes as you can to support your child’s skin. As for advice, I would double check your toothpaste for SLS – sometimes people think they are using an SLS-free paste but then find it hiding in there! Fluoride-free AND SLS-free is key. Hormonal changes can definitely play a role, and there’s not much we can do to change hormone fluctuations in growing kids. In these cases, it’s important to support your child with stress reduction, healthy diet, and really clean personal care products. Also, remember to remain calm in your approach, and try not to change too much too often – if you take a slow, patient approach, you will likely help your child have better results. Probiotic supplements are also a great addition, especially if you are excluding dairy from the diet. And, if you want to try any sample of Osmia products, we sell sample sizes of all products on our site – I know it’s hard to spend money on something until you know whether it will help!

Wishing you all the very best, and sending hugs to your little people,
Sarah.

Sarah Villafranco, MD on January 05, 2015

Hello,
I have had PD for about 4 months now and am trying to fight it naturally. I started the soothing kit and love it, although my PD hasn’t quite cleared up yet. I recently cut out all sugar and I think that is helping a lot. I am wondering how much primrose oil I should be taking per day. Currently, I follow the recommended dosage on the bottle but thought that you might have recommendations on how much to take for maximum effectiveness. Thank you!

Kristina on January 05, 2015

Lewis, my 7 year old is in the same boat as your 8 year old. Started as an eczema spot in August 2014 … then I applied steroid cream … like many here did not know that that was wrong wrong wrong. Ugh. Do not want to do an oral antibiotic as we have worked for the last 6 years to restore his gut. Trying metro gel, (on day 2) but that is chapping it and making it angry. If you find answers, please return and let me know how you fare. :) I will do the same.

Lexie on January 03, 2015

My is 8 yo has got it about 8 weeks ago. She is only 8!! it started very small above her upper lip and I thought it was a cold sore at first. My daughter has been using SLS free products for years now, is on homeopathic drainage treatment for a year now, and homemade mostly food, and limited sugar diet for many years now. We have been seeing the naturopath for an unexplained loos stools and he had put her on wheat, sugar and cow dairy free diet. Her stool has been improving a few months ago and it was okay go allow more flexibility in her diet. The little spot started to grow and spread and I took her to see the ND again who said she was on the best support and it will resolve soon. When it didn’t I took her to the family Dr and he wanted to give her 6 weeks of antibiotic which I refused. Have been trying colodial silver, ACV, allow and now Honey and turmeric. Don’t know what else to do. Not sure what can trigger in her case as she has always used SLS/fluoride free products and so do we. Hormones.. at her age,? and we use organic or natural meats without the use of hormones or antibiotics. I feel helpless and feel for my poor DD to have to deal with this now, she’s just a little girl.. I would appreciate to hear any thought or similar story and experience. Thanks!

Lewis on January 01, 2015

I am curious of experiences with PD & children. My 11 year old daughter had a bout of it last summer and was diagnosed by a dermatologist. I opted not to put her on antibiotics and it has resolved with using new toothpaste and shampoo. I chalked it up to hormonal changes, however my son, age 9 now has it around his nose and mouth. His looks more severe and flaky. I’m now paranoid it is something environmental. Thanks for your perspective.

Alissa on December 30, 2014

@ Rose – I don’t think it matters that the toothpaste doesn’t get out of your mouth. Just the exposure to SLS and fluoride is enough of a trigger for those who are sensitive to them. As for the Black Clay soap, most people use it 1-2 times a day. We sell samples on our site so you can try before you commit to a full size bar.
@ Chelsea – Your skin will definitely be more upset if you are changing your routine frequently. I hope your skin settled down a bit for the wedding, and now you can take a slow and steady approach to healing it, using all the ideas mentioned here and in the FAQ blog post, as well. You can always email us with questions.
@ Leslie – MCAS will not be the cause of PD for most people, but it’s great that you have figured out that it is part of the problem for you. That’s one reason why PD is so hard to treat – it’s a totally different beast for each person! I will definitely refresh my memory on MCAS (not something I treated in the ER very often!) and add it to my list of potential causes/exacerbators for PD symptoms. Cleansing with coconut oil makes my PD completely spaz out, so it really is tricky to make universal recommendations. I hope we can provide a good, basic framework, on top of which people can experiment and systematically track their own individual symptoms. Thanks for your input!

Love to all,
Sarah

Sarah Villafranco, MD on December 29, 2014

I know this is an old post, but I wanted to share some info that might help. I have had issues with my skin since childhood. Sensitivities, peeling, rashes, you name it and I’ve had it. My facial skin has progressively worsened into my 40’s, and I now know that it is related to a condition I have called Mast Cell Activation Syndrome where the immune system mast cells inappropriately dump their chemical mediators in response to a variety of triggers with are different for each patient. I mainly get migraines, but I also now get pretty classic perioral dermatitis that is triggered worst by the use of NSAID medications like aspirin and ibuprofen. I first was able to determine the connection when trying a prescription NSAID called Mobic which caused a huge case of PD, but took 10 days on the medication to develop. It took 3 months to clear, during which time other triggers like dairy would exacerbate it. I recently tried to desensitized to low dose aspirin (unsuccessfully) for treating my MCAS, and and the PD is even worse this time.

Many with MCAS react strongly to fluoride or sodium laurel sulfate, as well as some of the main food allergens like wheat, dairy, eggs, soy, etc, so those things are all well worth trying to eliminate experimentally to see the impact on symptoms. It is worth noting that other common mast cell triggers are alcohol (topical and beverage), vinegar, fermented foods, high histamine foods like strawberries and spinach, and opiate painkillers. If i have an alcoholic beverage tgese days, I not only feel poisoned, I am also guaranteed a huge outbreak of facial lesions the next morning that are closer to boils than PD. Not everyone with MCAS gets PD, and I’m not suggesting that everyone with PD has MCAS, just that there might be some commonality with the way the immune system seems to be riled up in both conditions.

I use onlyour coconut oil as cleanser, and even water makes my skin red and inflamed. CeraVe cream is the only thing I currently tolerate as moisturizer, and Vanicream zinc diaper rash cream is somewhat protective and soothing. There is a trick that the MCAS patient groups have developed for skin reactions that some may wish to try. There is a mast cell stabilizing medication called cromolyn sodium that is available in OTC form in the nasal spray Nasal Crom, and ithe can be aplied directly to irritated skin on a coton ball or mixed with a neutral moisturizer like Vanicream and applied to help reduce inflammation.

I hope some of these tips can help some of you. I totally understand how awful this condition makes you feel. Please note that none of my triggers show up on traditional allergy testing, and all developed later in life (some quite suddenly) so something you consider safe might not be any longer.

Leslie on December 27, 2014

Hello-
I have been suffering with off/on PD brake-outs since October 2014. I went to the Derm who prescribed me a topical steroid. By December the flare up was full blow. I went back to the deem who then prescribed me Sodium Sulfactamide Lotion, and Acticlate. I have been taking the oral meds, and using the lotion twice a day and my face looks angrier then before and spreading. I just began to use my OO soothing kit today. I am in a wedding Saturday (today is Wednesday) I called the deem back who said to use Hydrocortisone cream until after the wedding. Do you have any helpful suggestions? I feel like my skin is going crazing using so may methods at once.

Chelsea miller on December 24, 2014

Hello. Would the Osmia black clay soap be appropriate for daily washing? I’d love to use it as a replacement for my current face washing regiment! My face is normal, with mild PD off and on for the past 6-7 years that is treated very effectively with topical prescription ointments. After reading your post, I am willing to eliminate SLS. Currently I use organic flouride toothpaste, but it doesn’t get “out” of my mouth, in other words, I don’t let it run down my chin nor do I spit it out, so there’s no risk of it trickling with water down my chin. Do I still need to avoid flouride toothpaste if it doesn’t come in contact with my outer skin layers? I am going to consider your PD starter kit as well. I’m very excited about coming across your products.

Rose Lagun on December 19, 2014

Hey everyone!

I feel your pain, i’ve been suffering since April. It seemed to have started after a trip to Colorado where the air is very dry, the only connection I can make it using an under eye roller on sensitive, possibly microscopically torn skin. I went to a derm that told me it could have been a spider bite and gave me steroid cream. The cream kept it at bay, but never clear it up. Recently, I began researching online to see what I could do to fix it naturally….well I stopped the steroid cream immediately after reading how connected the two are. Immediate flare up, really bad, all around the side and underneath my eye. It was HORRIBLE. It is finally starting to clear after hitting it from all angles. Here was my potion and how it may or may not have helped:
Apple Cider Vinegar-HELPED! on the rash (it burns, you can dilute)
Drinking Apple Cider Vinegar (Dr. Braggs)
Colloidal Silver in my eye and around the rash-helped!
TONS OF FLUIDS, lots of water and tea everyday all day.
NO SUGAR- seriously, I’m convinced there is a connection
Probiotic- I used the vaginal support probiotics, these also seemed to help alot
no gluten-no sure if there was a change
Zinc supplement-unsure of change
Biotin-unsure of change
Florasone- a homeopathic eczema cream, seemed to help ALOT no steroids in this
Some coconut oil-seemed to help, but I’ve recently stopped and it’s gotten better, not sure if there is a connection
Washed face with African black soap every other day
Used ACV as a toner over entire face in AM.
I also threw out every single product with sulfate (i used a hotel shampoo when rash seemed to be getting better and it EXPLODED the next day, has to be connected!)
I also completely stopped using all makeup, apparently bare minerals has an ingredient known to aggregate skin, so don’t even think of trying to cover it.

Good luck everyone, this is such an awful thing to go through, especially on your face!!

nic on December 11, 2014

I had first noticed the irritation on my skin around June 2014. I’ve had issues with hormonal acne around my chin and neck for over a decade so I tried to treat it the same way and it flared up horribly. When I went to my Dermatologist, I was prescribed an acne medication that dried it out and made it even worse and incredibly painful. I started using OO products around that time after reading about PD, being pretty sure that that is what I had. It immediately calmed down the irritation (I used the black soap, active toner and simple face cream) after a few weeks it was much better, but I’m impatient and I went back to my Derm and told him my thoughts and thankfully he agreed and put me on an oral medication that helped with the lingering redness in my smile lines. I’ve removed SLS from my routine, and have kept up with washing my face twice a day with black soap and using the toner and lotion morning and night. I wear much less make up because my skin looks better than it has in a long time. It’s even helped with the acne I used to get along my jaw line. I’m really thankful to have found these products. They are not inexpensive, but they work, and really last a long time! Its much better than trying many products and throwing them away when they don’t work. It makes me personal care routine that much easier.

Maggie on December 10, 2014

Hi – Just a note of encouragement to all my fellow PD sufferers.. It takes a while, but you’ll get there! Mine cropped up in April this year around my eye lids and a patch along my jaw line. I had no idea what it was. By June, the corners of my eyes were cracked, bleeding and so painful. I discovered Osmia (thank you!!) later that month, adopted the no fluoride, no SLS, no refined sugar, etc regimen, which started to get things under control. But then a 12-day work trip (read: 12 days of wearing makeup during a sweaty July heatwave in the UK) and it spread to both smile lines around my mouth and my chin. By August, my face looked like it was covered in poison ivy, And it hurt terribly! All along, I knew that Sarah had said steroids make it worse but I wasn’t using any anti-zit cream or anything like that. A year prior to all this, I’d gotten psoriasis for the first time on the back of my neck — and finally I realized the prescribed spray for that was a steroid. I felt like such an idiot! So my choice: either let my psoriasis rage or could suffer from PD on my face. I vainly chose the psoriasis hidden under my hair. After 3 weeks of forgoing the psoriasis meds, the PD was so much better. It’s taking a long time to fully clear up (posting this in December) and I still have wide patches of dark red scarring in my smile lines, but overall it is light years better. I also found an all-natural African black soap scalp cream by Shea Moisture that is not curing, but greatly helping my psoriasis. Long/short – stick with it, don’t give up, don’t slack on the routine – you’ll get there!

Liz on December 07, 2014

@Courtney Yes, it is possible to have the symptoms of PD just around the eyes, in which case it’s called periocular dermatitis. The eye area is so sensitive that it can sometimes be even more difficult to treat than the perioral region. It can be so frustrating! Be sure to double check your toothpaste for SLS and feel free to email us on the site if you have specific questions.

Sarah Villafranco, MD on December 07, 2014

Hi, I know this is posting is a bit older so I am not sure if you are still taking comments on it. I have been suffering from what I believe to be perioral dermatitis only around the eyes since July. I know it is not blepharitis because it looks and feels very differently from how blepharitis is described. I think it was triggered by the use of nasal steroids for seasonal allergies and then facial steroids to clear the problem compounded it. It is very frustruating. Everytime I think I have found a solution, the solution stops working after a few days. Perhaps I am not sticking it out long enough? I see that sugar triggers the condition as well and I try to keep my diet almost completely sugar free except for a daily piece of fruit and a drop of honey in my one cup of coffee. I’ve stopped flouride, sodium laureth sulfates and cinnamon. I guess my question is, according to your expertise, is it possible to have perioral dermatitis around the eyes only with no symptoms around the nose and chin?
Thank you so much!!

Courtney on December 07, 2014

Hello…I have been battling this condition for the past four months. I am at a loss why it popped up since I led/lead a very organic lifestyle. Before the condition came, I did not use/ingest products suspect of causing PD like those with fluoride, SLS, caffeine, artificial flavorings, or gluten. I also ate an organic and genetically modified-free diet. I had not used a steroid cream. I was in great physical condition. I am so frustrated with the treatments…antibiotics have given little result and I have had some side-effects as well. I have had little results with nautral treatments and am leary to try this product too. I am feeling defeated. Just had to vent….

Jessica on November 22, 2014

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

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