Perioral Dermatitis and Causes of a Red Ring Around the Lips

How to manage skin inflammation around the lips

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Perioral dermatitis (PD) is a scaly, itchy rash that often appears as redness around the lips. It may extend up and appear as a mouth rash or there might be some clear skin in between. It may also spread to other areas of the face and body, and may appear similar to other conditions like lip licker's dermatitis or even rosacea.

Also called periorificial dermatitis, this condition causes symptoms such as:

  • Red bumps
  • Flaky skin
  • Clear fluid discharge
  • Inflammation

This article explains the causes of perioral dermatitis and what the rash looks like. It also explores how this rash is diagnosed, as well as available treatment options.

Rash around child's mouth.
James Heilman, MD / Wikimedia Commons / CC BY-SA 4.0

What the Rash Looks and Feels Like

PD appears as redness and itchy lips. The rash may consist of small, red bumps around the mouth called papules. You may also have dry, flaky, or scaly skin and a clear fluid discharge.

The rash may itch or burn. In some cases, it can spread to other parts of the face, such as the nose and eyes. Rarely, the same rash may appear around the genitals.

Assigned females are more likely than males to develop PD. The condition is also most likely to occur in people between the ages of 16 and 45. Children can also develop PD.

Causes of Perioral Dermatitis

The causes of perioral dermatitis are not well understood, and there is limited research on why symptoms of perioral dermatitis may emerge. The use of prescription steroids or some personal care products is often associated with the condition.

In some cases, there may be an underlying infection or hormonal or autoimmune disorder. Environmental factors also may play a role, but the evidence is limited for effects like fluoride exposure.

Steroids

Steroids are a type of anti-inflammatory medication. Their use, especially long-term, has been closely linked to perioral dermatitis. This is true for topical steroids and for steroids that are inhaled through the nose or mouth.

If you are using a steroid cream or steroid spray, especially for long periods of time, watch for symptoms of PD.

Sunscreen

In children, high sun protection factor (SPF) sunscreen may contribute to this lip rash. However, it may depend on what type of sunscreen is used, and there are even some theories to suggest that it's actually the ultraviolet (UV) exposure to the sun that contributes to perioral dermatitis.

Beauty Products

Makeup, especially foundation, may also cause PD. Some cleansers and shampoos contain sodium lauryl sulfate (SLS). This compound is known to irritate sensitive skin, which may lead to perioral dermatitis.

The use of heavy face creams and moisturizers may also cause perioral dermatitis. Those that contain certain ingredients, like paraffin and petroleum jelly, may be particularly problematic.

Toothpaste

A few case reports have suggested a link between fluoride toothpaste and PD. Flavoring may play a role in allergic reactions causing bumps on the lips.

Some researchers suggest allergies to dental fillings also may be a cause of PD symptoms.

Hormone Fluctuations

Hormonal changes and factors that affect PD symptoms include oral contraceptive use, pregnancy, and premenstrual flares. It may be an underlying reason for why assigned females account for the majority of cases in adulthood (about 90%) but the diagnosis is rare in children.

Yet other hormones beyond female sex hormones (estrogen, progesterone) may be at work with PD. For example, there are reported cases in children treated with growth hormone therapy.

Oral Contraceptives

While oral contraceptives and hormonal changes have been considered as causes of perioral dermatitis, there's also evidence that symptoms improve with oral contraceptive use. More research is needed to better understand the relationship with PD.

Environmental Factors

Researchers believe environmental conditions like heat and wind may play a role in someone developing this condition. UV light exposure also may be a factor.

Contact with allergens that lead to a skin reaction, or excessive water loss and dryness, also are possible environmental causes.

Immune System

Mineral or vitamin deficiencies (zinc, for example) may play a role in PD development. Recent studies are exploring the impact of diet and nutrition on inflammation and the immune system, and how this may influence PD due to the concept of the "gut-skin axis."

Zinc also has been shown to improve PD symptoms associated with a rare hereditary condition called acrodermatitis enteropathica.

What About COVID-19 and Masking?

Some researchers have found that masking the face due to the COVID-19 pandemic has led to perioral dermatitis and other skin conditions, or worsened existing symptoms. This may be due to bacteria buildup behind the mask, or friction and irritation with the mask fabric.

How Perioral Dermatitis Is Diagnosed

There is no test to diagnose PD. Your healthcare provider can diagnose it based on your symptoms.

Seeing a dermatologist—a physician who specializes in skin conditions—may be helpful, as they may have more experience spotting cases of PD than other physicians.

Your practitioner may work to rule out other similar conditions as part of the diagnostic process. These include:

  • Impetigo: This skin infection is common among school-age children and is easily spread. Symptoms include red, oozing sores around the nose or mouth.
  • Seborrheic dermatitis: This rash is usually seen in the creases around your child's nose. It may cause flaking behind the ears and eyebrows.
  • Angular cheilitis: Iron deficiency and teeth issues can lead to inflammation and flaking at the corners of the mouth.
  • Lip licker's dermatitis: Kids may suck their lower lip or lick their lips, especially during the winter. As the skin around their lips gets dry and irritated, your child may develop a rash.
  • Sexually transmitted infection: Symptoms of syphilis can include mouth sores and ulcers that can cause redness around the lips.

Treatment Options

PD may go away on its own, but it depends on the cause. If you use a steroid cream or spray, your healthcare provider may recommend that you stop doing so as a first step. It's important to note that the rash may get worse before healing. Use a gentle facial soap while your rash heals.

Symptoms may resolve if you limit exposures (like mask-wearing or fluoride toothpaste) or correct a zinc deficiency. But it's possible that discontinuing the use of products like sunscreen may not be enough to clear the rash in a matter of days.

Prescription Medications

In some cases, prescription medications may be recommended. The most commonly prescribed medication is an antibiotic, and it may be used for weeks to months.

Topical antibiotics are common (such as an erythromycin gel or metronidazole) and they can be used in moderate to severe cases along with oral antibiotics like tetracycline or doxycycline.

Elidel topical cream, a medication commonly used for an eczema rash, also is an option.

Perioral dermatitis can recur, even with treatment. You may go through periods of flare-up and periods where you have no symptoms. For some patients, long-term management of the condition may be necessary.

Preventing Perioral Dermatitis

Some experts suggest that avoiding use of over-the-counter products on your skin is a priority. These products can include:

  • Cosmetics
  • Hydrocortisone creams
  • Acne medications like benzoyl peroxide
  • Moisturizers

If you are prescribed steroid medications, talk to your healthcare provider. You may need to permanently discontinue these medications to prevent flare-ups. It's also helpful to discuss other medications or conditions that may contribute to PD symptoms, such as pregnancy.

Summary

PD is a red, bumpy, flaky rash that typically shows up around the lips. It may also be found on other areas of the face and body. Children and assigned females tend to be diagnosed most often with this rash.

While there isn't a medical test to diagnose this rash, a dermatologist will be able to identify it based on your symptoms. They may offer treatment suggestions such as:

  • Taking an oral antibiotic
  • Using a topical antibiotic
  • Stopping the use of any steroids and/or fluoride products

There is strong evidence that PD may be related to the use of prescription steroids. This includes both topical and inhaled steroids. Talk to a dermatologist about the best treatment options for you. Working closely with your healthcare provider will give you the best chance of successfully clearing your rash.

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By Vincent Iannelli, MD
 Vincent Iannelli, MD, is a board-certified pediatrician and fellow of the American Academy of Pediatrics. Dr. Iannelli has cared for children for more than 20 years.