Photo Quiz

Recurrent Facial Rash

 

Am Fam Physician. 2020 Nov 15;102(9):625-626.

A healthy 34-year-old patient presented with a worsening facial rash that first appeared about two years earlier. The rash was initially painless but developed a moderately intense burning sensation with repeated flare-ups. There was no scarring or pruritus.

Two years earlier, the patient underwent a left total temporomandibular joint replacement. Bacitracin ointment was applied to the incision site postoperatively, causing an irritant contact dermatitis that was treated with topical triamcinolone. Two weeks after stopping the triamcinolone, a new perioral rash developed. This rash also cleared after a few days of triamcinolone treatment. This pattern of recurrence after discontinuation of triamcinolone continued, with each recurrence becoming more intense.

On physical examination, the patient had a normal body mass index and vital signs. Multiple clustered, erythematous papulopustules without scales were noted in the perioral area (Figure 1). The patient had no cervical lymphadenopathy or other clinical findings.

FIGURE 1


FIGURE 1

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

  • A. Acne vulgaris.

  • B. Allergic contact dermatitis.

  • C. Impetigo.

  • D. Perioral dermatitis.

  • E. Rosacea.

Discussion

The answer is D: perioral dermatitis. Perioral dermatitis is a relatively common skin disorder that typically presents as small, clustered inflammatory papules around the mouth or nose. Although pathogenesis is not well understood, use of topical corticosteroids such as triamcinolone can be a contributing factor.1,2 Perioral dermatitis may be asymptomatic or associated with a mild to moderate burning sensation.3 The rash initially improves with topical corticosteroid treatment but recurs or worsens with continued use or attempts to discontinue treatment. Use of skin moisturizers, cosmetics, or fluoridated toothpaste may also be associated with perioral dermatitis.4

Perioral dermatitis is considered a self-limited condition. It may resolve spontaneously within a few months or persist for several years. Management begins with

Address correspondence to Jason Ramirez, MD, at jramirez101481@yahoo.com. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Nguyen V, Eichenfield LF. Periorificial dermatitis in children and adolescents. J Am Acad Dermatol. 2006;55(5):781–785....

2. Hafeez ZH. Perioral dermatitis: an update. Int J Dermatol. 2003;42(7):514–517.

3. Wollenberg A, Bieber T, Dirschka T, et al. Perioral dermatitis. J Dtsch Dermatology Ges. 2011;9(5):422–427.

4. Hall CS, Reichenberg J. Evidence based review of perioral dermatitis therapy. G Ital Dermatol Venereol. 2010;145(4):433–444.

5. Oppel T, Pavicic T, Kamann S, et al. Pimecrolimus cream (1%) efficacy in perioral dermatitis – results of a randomized, double-blind, vehicle-controlled study in 40 patients. J Eur Acad Dermatol Venereol. 2007;21(9):1175–1180.

6. Weber K, Thurmayr R. Critical appraisal of reports on the treatment of perioral dermatitis. Dermatology. 2005;210(4):300–307.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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