Patients will come in to the office complaining of a rash around the mouth or nose, which tends to come up and then go away on the morning of their dermatology visit. They feel crazy when they explain to me, the dermatologist, how embarrassing and pesky this condition can be. They have certainly never had issues with their skin before, but now this is horrible. It is sort of a cross between acne and eczema. It comes and goes. Some things that they try like Neosporin or Cortaid may help temporarily, but then it comes back when they try to put the medication away in the medicine cabinet.

Perioral dermatitis is actually a very specific condition that is a little tricky to treat, depending on the patient. Some patients will respond quite well to first-line therapy that incorporates a topical anti-inflammatory that is NOT a steroid onto the skin when it flares. Others will go through several different topical medications before we settle on something that seems to control this annoying condition. Occasionally, I may add in an oral antibiotic medication because it can be helpful in decreasing the inflammation (not because it is considered to be an infection).

Perioral dermatitis is not appropriately treated with topical steroids. To treat this condition with topical steroids only creates a situation whereby the patient constantly has to re-apply steroids to an area that gets chronically inflamed. Chronic use of steroids on the skin can result in atrophy, or thinning, of the skin, and this is not reversible when you stop it. In fact, many times, the chronic use of steroids can lead to eventual non-responsiveness of perioral dermatitis.

Managed care plans and insurance companies love to practice medicine, even though they forgot to attend medical school and residency training. Since topical steroids are relatively cheap, patient insurance likes to demand failure to topical steroids before approving non-steroidal alternatives at a reasonable cost to the patient.

I will receive letters from patient insurance plans stating, “Must fail these designated medications before we will consider giving your patient this non-formulary alternative”. Next, they list 3-4 different topical steroids of varying strength. I like to explain to my patients that these insurance carriers do not have to carry malpractice insurance, nor will they be left holding the proverbial bag if the patient suffers from inappropriate medical treatment like steroid atrophy of the facial skin for long-term use. If available, I like to offer my patients with perioral dermatitis samples of medication to determine what works best, before they fill a trade size medication, and sometimes at their own cost if insurance denies coverage.

Perioral dermatitis, although annoying, can be controlled, but not cured. I can help manage patients in order to find what exact regiment works for them, as each patient is unique and different when it comes to this condition. Together, the patient/doctor team can actually succeed, despite what managed care may throw our way.