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Patient Case: Persistent Rash Around the Mouth

Patient Case: Persistent Rash Around the Mouth

Discussion

A 29-year-old woman presents with a three-week history of a red, bumpy rash around her mouth. She describes the rash as mildly itchy and sometimes burning, with small, pus-filled bumps that seem to worsen after applying her usual topical steroid cream. She denies any new skincare products, but she frequently uses heavy moisturizers and makeup.

She has no history of allergies, asthma, or eczema. She is otherwise healthy and has not had similar rashes before. The rash does not involve her lips but extends to the skin around the mouth and slightly onto the chin.

On examination, there are erythematous papules and pustules around the perioral area, sparing the vermilion border of the lips. There are no blackheads, and the rash appears worse in areas where she applied the steroid cream. A clinical diagnosis of perioral dermatitis is made.

She is advised to discontinue topical steroids, switch to a gentle, fragrance-free skincare routine, and start a topical antibiotic (metronidazole or clindamycin). A short course of oral doxycycline is prescribed for more severe inflammation, and she is counseled to avoid heavy creams and fluoridated toothpaste.

Questions
1. What is the most likely diagnosis in this patient?

a) Acne vulgaris
b) Perioral dermatitis
c) Seborrheic dermatitis
d) Allergic contact dermatitis

2. Which of the following factors most likely contributed to the development of this condition?

a) Frequent use of topical corticosteroids
b) Consumption of spicy foods
c) Poor facial hygiene
d) Vitamin deficiency

3. What is the most appropriate initial treatment for this patient?

a) Continue using topical corticosteroids for symptom relief
b) Discontinue topical steroids and start topical metronidazole or clindamycin
c) Apply antifungal cream to the affected area
d) Perform an allergy test before initiating treatment

4. Which of the following recommendations can help prevent recurrence?

a) Avoid heavy moisturizers and use gentle, fragrance-free skincare products
b) Wash the face with strong antiseptic cleansers twice daily
c) Use high-potency topical steroids at the first sign of recurrence
d) Stop using oral antibiotics immediately after the rash improves

Reveal answers

Answers

  1. (b) Perioral dermatitis
    • The presence of red papules and pustules around the mouth (sparing the lips), worsening with topical steroid use, and no blackheads strongly suggests perioral dermatitis. Acne vulgaris (a) typically involves comedones (blackheads/whiteheads), seborrheic dermatitis (c) presents with greasy scales, and allergic contact dermatitis (d) would have a clear trigger with a more acute reaction.
  2. (a) Frequent use of topical corticosteroids
    • Topical steroids are a major trigger for perioral dermatitis, as they disrupt the skin barrier and promote inflammation. Spicy foods (b) and vitamin deficiency (d) are not primary causes, and poor hygiene (c) is not a contributing factor—this condition is not caused by unclean skin.
  3. (b) Discontinue topical steroids and start topical metronidazole or clindamycin
    • The first step in treatment is to stop using topical steroids, even if they initially seemed to help. Topical antibiotics like metronidazole or clindamycin are preferred, and oral antibiotics (doxycycline) may be used in severe cases. Antifungal creams (c) are ineffective, and an allergy test (d) is unnecessary for diagnosis.
  4. (a) Avoid heavy moisturizers and use gentle, fragrance-free skincare products
    • To prevent recurrence, patients should avoid heavy creams, fragranced products, and topical steroids. Harsh antiseptic cleansers (b) can irritate the skin, high-potency steroids (c) should never be used, and oral antibiotics (d) should be taken as prescribed to prevent relapse.

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