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Worrisome perioral rash on a young boy

Colette Caputo, MCMS, PA-C

Colette Caputo practices at the Center for Dermatology, Coral Springs, Florida. She has indicated no relationships to disclose relating to the content of this article.

CASE

A 9-year-old African-American male was brought to the dermatology clinic by his mother because she was concerned about a dark, elevated, ring-shaped rash around the boy’s mouth. The rash had progressively worsened over the past year. The boy denied itching or pain in the area and complained only of minimal dryness and irritation. The mother denied a history of allergies, asthma, or eczema in her son. The patient was not taking any oral medications or utilizing any topical preparations. He had not eaten mangos or citrus fruits, nor had he used toothpaste that contained whitening agents. However, he habitually licked his lips.

Physical examination The patient appeared well-nourished and at the appropriate stage of development for his age. He was alert and oriented × 3. A 3-mm, erythematous, hyperpigmented, lichenified, dry, scaly, annular plaque was noted around the perioral area (see Figure 1). The labial mucosas appeared mildly edematous without fissuring but were otherwise well intact. No other primary lesions or eruptions were seen around the perioral area or within the oral cavity. No signs of an infectious process were found.

WHAT IS YOUR DIAGNOSIS?

Perioral dermatitis
Lip-licker’s dermatitis
Allergic contact dermatitis
Tinea faciei

DISCUSSION

This patient has lip-licker’s dermatitis, a benign inflammatory skin condition that is most commonly observed in children with a history of atopy or overly sensitive skin. The condition is often caused by repetitive epidermal irritation that causes well-demarcated areas of erythema, scaling, thickening, fissuring, and pigmentary changes that often resemble the exaggerated mouth make-up of a clown. The diagnosis is routinely based on the clinical presentation and usually does not warrant a skin biopsy or culture.

Comment Treatment includes discontinuing the causative behavior and applying a lubricating or moisturizing agent to restore the skin barrier. Often, a low-dose topical corticosteroid is included to help reduce localized inflammation. If severe lip-licker’s dermatitis is not treated in a timely fashion, permanent postinflammatory hyperpigmentation and/or scarring may ensue.

Perioral dermatitis is a common eruption that manifests as discrete inflammatory papules and/or pustules around the mouth, often overlying an erythematous or scaly base. The eruption typically spares the vermillion border but may be noted around the perinasal and infraocular areas.

Allergic contact dermatitis is an erythematous, scaly, edematous, pruritic eruption that is not well demarcated in nature. If the condition manifests around the mouth, the vermillion border demonstrates irritation.

Tinea faciei, also called ringworm, is a superficial dermatophyte infection of the glabrous skin that can appear anywhere on the face. The infection often manifests as annular, pruritic, erythematous, scaly patches or plaques with elevated borders.

Treatment Our patient was instructed to avoid licking his lips and to apply petrolatum or Aquaphor Healing Ointment to his lips and the surrounding skin areas several times a day. In addition, the patient was to apply desonide ointment (DesOwen) twice a day for 2 weeks. At 2-week follow-up, significant improvement was noted with only mild macular hyperpigmentaton around the mouth. The patient was instructed to continue moisturizing as directed and also to apply a facial moisturizing sunscreen with an SPF 30+ daily. JAAPA

Joe R. Monroe, PA-C, MPAS, department editor