Topical treatments fail to resolve a young woman’s facial rash.
A 24-YEAR-OLD female patient presents with a 12-month history of an irritable red papular and scaly rash around her nostrils and chin. This has fluctuated in severity over the past 12 months.
She has tried many different treatments, including hydrocortisone, betamethasone, triamcinolone, mometasone and Kenacomb creams. While these creams initially helped the rash, the rash flared as soon as the creams were stopped.
The patient is unable to go to work if the rash is bad and is extremely distressed by the appearance of her face.
WHAT IS YOUR DIAGNOSIS?
Perioral dermatitis (steroid-induced rosacea).
WHAT IS YOUR PLAN OF MANAGEMENT?
Cessation of topical steroids and explanation to the patient that the rash is likely to flare significantly over the subsequent two weeks and will then settle down over the ensuing two to three months.
You also prescribe doxycycline 50 mg per day to hasten the resolution of the perioral dermatitis.
PERIORAL DERMATITIS
Perioral dermatitis is a common rash that occurs on the face, around the mouth, nose or eyes, secondary to the use of stronger topical steroids. It has also been reported to occur on the face in those who use moisturisers and foundation on a regular basis.
Stronger topical steroids, such as betamethasone and mometasone, are the most common agents that cause perioral dermatitis in Australia today.
The most effective treatment of perioral dermatitis is to stop the creams that the patient has been using and, in particular, to stop the stronger topical steroid preparations if they have been used.
Tetracyclines are the mainstay of therapy, although erythromycin can be used in those patients in whom tetracyclines are contraindicated. These may need to be continued for up to three months.
A short period of a weak topical steroid, such as 1% hydrocortisone cream (for two to three weeks), or a non-steroid anti-inflammatory agent, such as pimecrolimus cream for a period of two to three weeks, will also reduce the flare that occurs after the cessation of the strong topical steroids.
Reassurance that this rash will settle is required. The appearance of the rash after the cessation of the stronger topical steroids can be very florid, and during this time a lot of reassurance is required that the rash will settle but may take several months to do so.
Dr Stephen Shumack is the Honorary Secretary of the Australasian College of Dermatologists.