Perioral dermatitis
Michael A. Siegel, DDS, MS
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THE CHALLENGE
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A 5-year-old boy visited me, in the company of his mother, for diagnosis and treatment of a left-sided perioral dermatitis of 18 months’ duration (Figures 1
and 2). At the time of the lesions’ onset, the patient had just recovered from pneumonia. He was otherwise healthy.
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Figure 1. Perioral rash with an eczematous appearance confined to the area approximating the left labial commissure.
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Initially, the patient’s pediatrician made a diagnosis of chapped lips and attempted to administer topical therapy with petroleum jelly (Vaseline, Unilever, London). As the process worsened, a second pediatrician, two general dentists, a pediatric dentist and three dermatologists examined the patient. The clinicians made several diagnoses, such as contact dermatitis, fungal cheilitis, impetigo and ringworm, and then ruled them out. Treatment included a four-month trial of amoxicillin/clavulanic acid, as well as topical therapies that included emollients, steroids, antifungals and antibacterials.
A cytologic examination and culture revealed desquamated epithelium and group D streptococci. The dermatologists made a nonspecific clinical diagnosis of eczematous dermatitis and chose not to perform a cutaneous biopsy, because of the benign presentation of the lesions and the psychological and physical trauma to the child. The patient had two younger brothers who did not exhibit any signs or symptoms. The patient’s signs were confined to the left perioral region; no other cutaneous or intra-oral sites were affected.
Can you make the diagnosis?
- impetigo
- herpes zoster
- lichen planus
- contact hypersensitivity reaction
- trauma from lip licking
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THE DIAGNOSIS
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D. contact hypersensitivity reaction
Perioral and intraoral contact hypersensitivity reactions are a poorly understood clinical reaction to a soap, a cosmetic, a food, an oral hygiene product or a dental material.1,2 Recently, a number of reports appeared in the dental literature implicating flavoring agents and spices, as well as dentifrice and mouthrinse additives such as cinnamon and calcium pyrophosphate.3–7 Additives such as triclosan that are contained in both skin and dental products also have been implicated.8 These authors3–8 suggested that perioral and intraoral contact allergies may be more common than previously believed. These lesions frequently are misdiagnosed as trauma, lichen planus and discoid lupus erythematosus.
Oral hygiene regimen.
In this case, I considered carefully all of the patient’s previous treatments and their outcomes to ensure that the diagnoses had been ruled out properly. I interviewed the patient and his mother carefully with regard to traumatic habits such as thumb sucking, lip licking and chewing on objects, as well as sleeping habits and contact with soap, cosmetics and fabric softeners. I also inquired about the patient’s oral hygiene regimen regarding the specific types of dentifrice, mouthrinse and floss he used regularly. The patient said that he was using a mouthrinse containing cinnamon flavoring. During the examination, I gave the patient a saline mouthrinse, and as he spit it out, the saline dribbled out of his left commissure and reproduced the exact distribution of the perioral lesions.
Replace mouthrinse.
I instructed the child’s parents to replace the cinnamon-containing mouthrinse with a mild solution containing 1 teaspoon baking soda in 16 ounces of water, with enough red food coloring added to simulate the original mouthrinse. In this way, the child could continue to rinse and acquire the coordination needed to perform this oral hygiene procedure properly. The patient returned for a three-week follow-up visit, and the lesions had resolved completely without scarring (Figure 3).
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CONCLUSION
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The key to diagnosing a contact reaction, whether it is associated with hypersensitivity or trauma, often is related to pattern recognition by the clinician. For example, a mucosal lesion such as a "pizza burn" or a leukoplakia related to amalgam contact often can be inferred by the location of the lesion. In this case, the unilateral distribution of the perioral dermatitis in a gravity-dependent location (that is, the lower lip rather than the upper lip) suggested a contact hypersensitivity reaction. To establish a definitive diagnosis, clinicians need to take careful histories.
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FOOTNOTES
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Dr. Siegel is a professor and chairman, Department of Diagnostic Sciences, College of Dental Medicine, Nova Southeastern University, 3200 S. University Drive, Fort Lauderdale, Fla. 33328-2018, e-mail "masiegel{at}nsu.nova.edu". Address reprint requests to Dr. Siegel.
Diagnostic Challenge is published in collaboration with the American Academy of Oral and Maxillofacial Pathology and the American Academy of Oral Medicine.
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REFERENCES
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- De Rossi SS, Greenberg MS. Intraoral contact allergy: a literature review and case reports. JADA 1998;129(10):1435–41.
- Pang BK, Freeman S. Oral lichenoid lesions caused by allergy to mercury in amalgam fillings (published correction appears in Contact Dermatitis 1996;35[1]:70). Contact Dermatitis 1995;33(6):423–7.[Medline]
- Serio FG, Siegel MA, Slade BE. Plasma cell gingivitis of unusual origin: a case report. J Periodontol 1991;62(6):390–3.[Medline]
- Miller RL, Gould AR, Bernstein ML. Cinnamon-induced stomatitis venenata: clinical and characteristic histopathologic features. Oral Surg Oral Med Oral Pathol 1992;73(6):708–16.[Medline]
- Cohen DM, Bhattacharyya I. Cinnamon-induced oral erythema multiformelike sensitivity reaction. JADA 2000;131(7):929–34.
- Moghadam BK, Drisko CL, Gier RE. Chlorhexidine mouthwash-induced fixed drug eruption: case report and review of the literature. Oral Surg Oral Med Oral Pathol 1991;71(4):431–4.[Medline]
- Beacham BE, Kurgansky D, Gould WM. Circumoral dermatitis and cheilitis caused by tartar control dentifrices. J Am Acad Dermatol 1990;22(6 part 1):1029–32.[Medline]
- Wong CS, Beck MH. Allergic contact dermatitis from triclosan in antibacterial handwashes. Contact Dermatitis 2001;45(5):307.[Medline]
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THE CHALLENGE
THE DIAGNOSIS
