Perioral dermatitis is a facial rash that presents as small red bumps and pustules around the mouth, nose, and sometimes eyes. It is consistently mistaken for acne or rosacea — and the misdiagnosis matters, because the treatments for acne (particularly topical steroids and certain moisturisers) are among the primary causes of perioral dermatitis. Treating it incorrectly not only fails to clear it but actively worsens it.

What Causes It

The exact mechanism is not fully understood, but topical corticosteroid use — even low-potency steroids and steroid-containing creams — is the most commonly identified trigger. In India, where potent topical steroids are widely available over the counter and frequently applied to the face for various reasons (fairness, eczema, irritation), perioral dermatitis is extremely common. Other identified triggers include fluorinated toothpaste, heavy occlusive moisturisers, and certain inhaled steroid medications. Perioral dermatitis is more common in women and frequently occurs during hormonal changes.

Why Steroids Make It Worse

Applying more topical steroid to perioral dermatitis initially suppresses the inflammation, providing temporary relief. But this creates a dependency — when the steroid is withdrawn, the rash rebounds worse than before, a phenomenon called steroid addiction or topical steroid withdrawal. Many patients caught in this cycle have been applying escalating potencies of steroid for months or years. Breaking this cycle requires complete steroid withdrawal, which produces an initial flare before improvement begins.

Treatment

The cornerstone of treatment is stopping all topical steroids — including any steroid-containing products the patient may not recognise as such. A simplified skincare routine is essential: gentle cleanser, a simple light moisturiser if needed, and sunscreen. Oral doxycycline at anti-inflammatory doses is the most effective treatment — typically 6-12 weeks. Topical metronidazole or azelaic acid can be used alongside or for milder cases. Complete clearance takes several weeks to months, and patients need to be counselled that initial worsening after steroid withdrawal is expected and temporary.

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— Dr. Nishita Ranka | Consultant Dermatologist | Dr. Nishita’s Clinic for Skin, Hair & Aesthetics, Hyderabad