Perioral Dermatitis: symptoms, triggers, and treatment
That Rash Around Your Mouth Might Not Be Acne:
A Guide to Perioral Dermatitis
by Bridget Alsup, MPAS, PA-C, FMCP-M
It starts with a few small bumps near you mouth. You treat it like a breakout, or you reach for a little over-the-counter hydrocortisone cream to help with the stinging and itching. It seems to be improving for a few days, but then it comes back and spreads.
If this sounds familiar, you may be dealing with a dermatologic condition called perioral dermatitis.
And, in clinical practice, I see it commonly mistaken for acne. The good news is it is very treatable, and the first step is usually doing less, not more.
What is Perioral Dermatitis (POD)?
Perioral dermatitis (*pair-ee-OR-al der-muh-TIE-tis*) is a rash of small red or pink bumps around the mouth. It can also show up in the folds beside the nose and around the eyes. When it appears in more than one of these areas, you may hear it called periorificial dermatitis.
A few things worth knowing:
It is not acne, even though it can look similar.
It is not contagious. You can't catch it or pass it to anyone.
It is most common in women ages 20 to 45, but men and children can get it too.
The telltale sign of POD:
The telltale sign is a thin strip of clear, normal-looking skin right along the edge of the lips. The rash usually stays just outside that border.
Common Symptoms of POD
Symptoms can come and go, or slowly build over several weeks:
Clusters of tiny red or pink bumps around the mouth, beside the nose, or near the eyes
Some bumps with a small clear or white head
Dry, flaky, or peeling patches that moisturizer doesn't seem to fix
Mild burning, stinging, or itching, often worse right after products touch the area
A tight, sensitive feeling in the skin
Why Does It Happen?
The exact cause isn't fully understood.
Most experts think the skin barrier becomes irritated and the skin's natural balance is thrown off, so the skin starts to over-react to things it touches every day.
That is why finding and removing your triggers matters so much. For most people, once the triggers are gone, the skin can calm down and clear.
The most common mistake: steroid creams.
Please don't treat this rash with hydrocortisone or any other steroid cream, even an over-the-counter one.
Steroids quiet the redness for a short time, then the rash comes back stronger. This sets up a frustrating cycle that can go on for months. Steroid nasal sprays and inhalers can play a role as well.
Good to know:
When you stop a steroid cream, the rash often gets worse for 1 to 2 weeks before it improves.
This "rebound" flare is normal and expected.
It doesn't mean the plan isn't working. If you use a prescription steroid for another condition, talk with your provider before stopping it.
Hidden Triggers, and What to Use Instead:
Beyond topical steroids, most people have other factors that are triggering their POD. A good place to start looking is at the products that come into contact with your face, lips, and hair.
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Fluoride, SLS (sodium lauryl sulfate, the ingredient that makes toothpaste foam), and cinnamon, whitening, or tartar-control flavors are common culprits.
Try instead: a mild, SLS-free, fluoride-free toothpaste, and rinse around your mouth with water after brushing. Fluoride protects your teeth, so ask your dentist about other ways to get that protection while your skin heals.
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SLS and other harsh cleansers rinse right down over your face in the shower and can trigger more flares.
Try instead: sulfate-free hair products. Rinse with your head tipped back, then wash your face last with a gentle cleanser.
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Thick moisturizers, rich night creams, and petroleum jelly can trap heat and moisture against the skin.
Try instead: a light, fragrance-free lotion, and only when your skin feels dry.
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Foundation, primer, powder, and some chemical sunscreens can keep the rash going.
Try instead: go bare when you can, and use an all-mineral sunscreen with zinc oxide instead of a chemical sunscreen.
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Scrubs, retinol, exfoliative acids, and switching products often all wear down the skin barrier.
Try this instead: Pare back your routine to the essentials, or consider transitioning to a restorative routine for 8-12 weeks to reset the barrier. Once you find a routine that works, stick to it. -
Makeup wipes, physical rubbing, lip licking, touching the rash, lip plumpers, and flavored lip balms can all trigger a flare.
Try instead: Pat face dry after cleansing with a clean, disposable towel. Avoid unnecessary additives in lip, skin, eye, and makeup products. Change your bed sheets and pillowcases often.
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Changes around your cycle, pregnancy, or starting / stopping birth control can play a role.
Let your provider know about any recent changes.
How is Perioral Dermatitis Treated?
Treatment works best as a step-up plan. We start gentle and add more only if your skin needs it.
Step 1: A Pared Back Routine
For mild cases, a restorative skincare protocol is often all it takes. Plan on following it for 6-12 weeks, depending on your skin’s response.
Wash with lukewarm water and a gentle, non-foaming, fragrance-free cleanser, then pat dry. Bring in gentle skincare products to help restore your barrier and calm overall inflammation like a hypochlorus acid mist, fregrance-free moisturizer, and all-mineral SPF (view Restorative Protocol below for my product picks).
Pause retinol, acids, vitamin C, scrubs, and facials until the rash clears
Make the trigger swaps above
Once your skin is clear, add products back one at a time so you can spot anything that causes a flare
Step 2: Prescription topical creams
If the rash is still active after a few weeks, or it is moderate from the start, a prescription topical cream can help.
Common non-steroid, prescription options include metronidazole, azelaic acid, ivermectin, and clindamycin.
In some cases, a compounded cream can combine ingredients in a gentle base made for your skin. Most people see improvement in 4 to 8 weeks.
Step 3: Oral medications
For widespread, stubborn, or frequently returning rashes, a low-dose oral medication from the tetracycline family, such as doxycycline, may be added.
It is used here for its anti-inflammatory effect, usually for about 6 to 12 weeks, then tapered off.
Other options are used during pregnancy, while breastfeeding, and for children as doxycycline is not safe in these patient populations.
What to Expect as You Heal
Keeping your triggers out of your routine is the best prevention, and treating early makes a flare easier to calm.
Weeks 1 to 2: a rebound flare is common as triggers, especially steroids, are removed
Weeks 2 to 4: fewer new bumps, less burning and flaking
Weeks 4 to 12: skin clears and settles. Healing is slow and steady.
Long term: perioral dermatitis can come back, be mindful of triggers and avoid coming into contact with them.
When to Reach out to Your Provider
Seek medical advice if:
The rash spreads, becomes painful, or starts crusting or oozing
You have eye redness, eye pain, or changes in your vision
A rebound flare feels severe or lasts longer than 2 weeks
You see no improvement after 4 weeks
You use a prescription steroid and aren't sure whether to stop it