Medication Summary
For mild disease, treatment can involve pimecrolimus, erythromycin, or metronidazole, either individually or in combination. Several small randomized controlled trials in adults support the efficacy of pimecrolimus in the treatment of perioral dermatitis [14, 15] . Case reports have also suggested that tacrolimus may be effective. [25] Small randomized trials also support the efficacy of topical antibiotics such as erythromycin and clindamycin [16] and topical metronidazole. [17] Case reports and small series have also suggested a potential role for topical azelaic acid [26] and adapalene [27] , though these should be used cautiously given the potential for causing irritation.
While randomized trials are lacking in pediatric populations, observational data suggest that pimecrolimus and metronidazole can be effective treatment options. [28]
For those with more severe disease or who do not improve after 4-8 weeks of topical therapy, treatment with oral tetracyclines is often indicated. [16] Doxycycline is typically preferred over minocycline due to the lower risk of severe adverse effects. [29] Emerging evidence suggests that sarecycline may also be a useful treatment option for perioral dermatitis. [30, 31] Sarecycline has a narrower spectrum of antibacterial activity than standard broad-spectrum antibiotics, which may reduce negative effects on the microbiome and the development of antibiotic resistance. [32]
Oral and topical ivermectin [18] , oral erythromycin [19] , oral and topical Janus kinase (JAK) inhibitors [20, 21] , and oral isotretinoin [22, 23] have also been suggested as potential treatment options .
Antibiotics, Other
Class Summary
These drugs may have antibacterial and/or anti-inflammatory effects that are responsible for their effectiveness in perioral dermatitis.
Metronidazole (Flagyl)
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Metronidazole is an imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. In concentrations of 0.75-2%, it is considered to be the drug of choice for topical treatment of perioral dermatitis. Metronidazole is available in a gel, lotion, or cream.
Erythromycin (E.E.S., Erythrocin, Ery-Tab)
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Topical erythromycin in concentrations of 2-4% as a gel or cream is an alternative to metronidazole for topical treatment. It inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. It is used to treat staphylococcal and streptococcal infections.
Clindamycin topical (Cleocin T, Clindacin P, ClindaDerm)
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Retinoid-Like Agents
Class Summary
These agents reduce the size of the sebaceous glands, decrease sebum secretion, and inhibit keratinization.
Isotretinoin (Amnesteem, Claravis, Sotret)
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Isotretinoin is an oral agent used to treat serious dermatologic conditions. It is a synthetic 13-cis isomer of naturally occurring tretinoin (trans -retinoic acid). Both agents are structurally related to vitamin A. Isotretinoin decreases sebaceous gland size and sebum production. It may inhibit sebaceous gland differentiation and abnormal keratinization. Isotretinoin is indicated for long-standing and refractory forms of perioral dermatitis. Because of adverse effects, therapy should be prescribed only by a physician familiar with this drug (ie, dermatologist).
A US Food and Drug Administration–mandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy.
Calcineurin Inhibitors
Tacrolimus ointment (Protopic)
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Pimecrolimus (Elidel)
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Pimecrolimus is the first nonsteroid cream approved in the United States for mild-to-moderate atopic dermatitis. It is derived from ascomycin, a natural substance produced by the fungus Streptomyces hygroscopicus var ascomyceticus. Pimecrolimus selectively inhibits the production and release of inflammatory cytokines from activated T-cells by binding to cytosolic immunophilin receptor macrophilin-12. The resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release. Cutaneous atrophy is not observed in clinical trials, a potential advantage over topical corticosteroids.
Tetracyclines
Sarecycline (Seysara)
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Doxycycline (Oracea, Doryx, Vibramycin)
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Doxycycline is the drug of choice in nonpregnant women. It inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Alternatively, one may use tetracycline in adapted dose.
Anthelmintics
Topical antibiotic
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