Treatment of perioral dermatitis with topical pimecrolimus.

To the Editor: Perioral dermatitis is a chronic facial eruption characterized by grouped reddish papules, papulovesicles, and papulopustules over an erythematous area around the mouth. Although perioral is the most frequent location, periocular areas, nasolabial folds, and glabella may also be affected.1Yung A. Highet A.S. Perioral dermatitis and inadvertent topical corticosteroid exposure.Br J Dermatol. 2002; 147: 1264-1281Crossref PubMed Scopus (15) Google Scholar Perioral dermatitis usually occurs in children and in young women between the ages of 20 and 45 years. Nevertheless, the number of adult male patients is assumed to be increasing because of changes in their cosmetic habits. The etiology is still unknown, although many factors have been proposed: contact allergy, hormonal factors, cosmetics, topical or systemic steroids, pregnancy, malabsorption, infective agents (eg, Candida, Demodex, Fusobacterium species), skin barrier disorders, or atopia.2Hafeez Z.H. Perioral dermatitis: an update.Int J Dermatol. 2003; 42: 514-517Crossref PubMed Scopus (65) Google Scholar, 3Dirschka T. Tronnier H. Fölster-Holst R. Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis.Br J Dermatol. 2004; 150: 1136-1141Crossref PubMed Scopus (123) Google Scholar Differential diagnosis of perioral dermatitis includes rosacea, seborrhoeic dermatitis, papular sarcoid, acne vulgaris, contact dermatitis (allergic or irritant), eruptive syringomas, xanthomas, glucagonoma syndrome, or lupus miliaris disseminatus faciei.4Hall Smith P. Unusual facial xanthoma.Clin Exp Dermatol. 1978; 3: 451-453Crossref PubMed Scopus (2) Google Scholar, 5Kasper C.S. Necrolytic migratory rythema: unresolved problems in diagnosis and pathogenesis. A case report and literature review.Cutis. 1992; 49: 120-122PubMed Google Scholar The use of all topical steroids should be avoided because they have been implicated in perioral dermatitis pathogenesis.2Hafeez Z.H. Perioral dermatitis: an update.Int J Dermatol. 2003; 42: 514-517Crossref PubMed Scopus (65) Google Scholar Topical metronidazole or erythromycin and oral tetracyclines have been used as conventional treatments. Liquid nitrogen, benzoyl peroxide, “zero-therapy” (observation without medical or cosmetic treatments), radiotherapy, azelaic acid, adapalene, and oral isotretinoin have also been reported as alternative treatments.6Array Jansen T. Azelaic acid as a new treatment for perioral dermatitis results from an open study.Br J Dermatol. 2004; 151: 933-934PubMed Google Scholar, 7Array Jansen T. Perioral dermatitis successfully treated with topical adapalene.J Eur Acad Dermatol Venereol. 2002; 16: 175-177Crossref PubMed Scopus (18) Google Scholar We present one case of perioral dermatitis with rapid response to topical pimecrolimus 1% cream. A 22-year-old white man presented with a 3-month history of cutaneous lesions around his mouth. A burning sensation was also noted. Medical history disclosed only Crohn's disease. At physical examination, multiple erythematous papulopustules ranging in size from 1 mm to 3 mm could be observed around his mouth (Fig 1). Topical steroids (Methylprednisolone aceponate 0.1% cream) had been applied after the eruption began without improvement of the lesions for 2 weeks. A diagnosis of steroid-damaged perioral dermatitis was made. Topical steroids were suspended and replaced with pimecrolimus 1% cream twice daily. The patient denied oral treatment. A complete clearance of the lesions was observed after 2 weeks (Fig 2). No adverse effects or recurrence have been noted at 4 months. Pimecrolimus is the most recently approved calcineurin inhibitor drug. It has been shown to be effective in several cutaneous inflammatory diseases, such as atopic dermatitis, inverse psoriasis, vitiligo, and oral lichen planus by inhibiting inflammatory cytokines in T cells.8Grassberger M. Steinhoff M. Schneider D. Luger T.A. Pimecrolimus—an anti-inflammatory drug targeting the skin.Exp Dermatol. 2004; 13: 721-730Crossref PubMed Scopus (101) Google Scholar, 9Esquivel-Pedraza L. Fernández-Cuevas L. Ortiz-Pedroza G. Reyes-Gutierrez E. Orozco-Topete R. et al.Treatment of oral lichen planus with topical pimecrolimus 1% cream.Br J Dermatol. 2004; 150: 771-773Crossref PubMed Scopus (44) Google Scholar, 10Amichai B. Psoriasis of the glans penis in a child successfully treated with Elidel (pimecrolimus) cream.J Eur Acad Dermatol Venereol. 2004; 18: 742-743Crossref PubMed Scopus (35) Google Scholar Nevertheless, the long-term safety of topical immunomodulators, such as tacrolimus or pimecrolimus, remains to be determined. An abnormality of the stratum corneum with an impairment of skin barrier functions is observed in perioral dermatitis, with an increasing penetration of exogenous agents, leading to contact dermatitis and irritant reactions. These are considered primary triggers of the disease.3Dirschka T. Tronnier H. Fölster-Holst R. Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis.Br J Dermatol. 2004; 150: 1136-1141Crossref PubMed Scopus (123) Google Scholar In recent reports, these triggers of perioral dermatitis have been considered similar to those in atopic dermatitis.3Dirschka T. Tronnier H. Fölster-Holst R. Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis.Br J Dermatol. 2004; 150: 1136-1141Crossref PubMed Scopus (123) Google Scholar This led us to suppose that pimecrolimus could be effective in our case. In fact, complete and rapid resolution of the lesions was achieved with topical pimecrolimus 1% cream, without adverse effects.