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Topical metronidazole gel (0.75%) for the treatment of perioral dermatitis in children
Topical metronidazole gel (0.75%) for the treatment of perioral dermatitis in children Sheryl R. Miller, MD, and Alan R. Shalita, MD Brooklyn, New York Three children with perioral or periocular eruptions were treated with topical metronidazole gel (0.75%) twice daily. Significant improvement was observed after 2 months. Complete resolution occurred after 14 weeks. (J AM ACAD DERMATOL 1994;31:847-8.) Perioral dermatitis is characterized by erythematous papules and papulopustules around the mouth and occasionally around the eyes. l Granulomatous perioral dermatitis appears to be a variant ofperioral dermatitis. Both conditions may occur in response to topically applied fluorinated steroid ointments but may also occur spontaneously. Reports of perioral dermatitis in children have appeared infrequently. In 1970, Gianotti et al. 2 described five children, aged 2 to 7 years, with a distinctive eruption around the mouth. The lesions consisted of asymptomatic skin-colored nodules 1 to 2 mm in diameter. Biopsy specimens demonstrated a lyrnphohistiocytic infiltrate with occasional giant cells. In these patients, the lesions tended to wax and wane for years and then resolved with pinpoint atrophy. Five children with perioral dermatitis were described by Frieden et al. 3 in 1989. Clinical and histologic findings for these patients were similar to those of our patients. Frieden et al. found that the response to treatment with oral erythromycin and low-potency topical steroids was variable. They believed that the eruption appeared to resolve spontaneously but therapy was warranted because of the potential for residual scarring. Marten et a1. 4 described a similar monomorphic facial eruption in 22 black children. They noted that the eruption cleared slowly and treatment with oral erythromycin and topical steroids was not beneficial. In 1990, Williams et al. 5 proposed an acronymFACE (Facial Afro-Caribbean Childhood ErupFrom the Department of Dermatology, Suny Health Science Center at Brooklyn. Reprint requests: Sheryl R. Miller Reisner, MD, 1 Yegia Capayim St., Ramat Hasharon, Israel 47263. Copyright © 1994 by the American Academy of Dermatology, Inc. 0190-9622/94 $3.00 + 0 16/4/54717
Fig. 1. Pretreatment photograph of pediatric perioral granulomatous dermatitis. tion)-to describe five cases of monomorphic papules with a central facial distribution. Two patients responded to treatment with oral erythromycin and in the other three patients lesions resolved spontaneously within 9 months. CASE REPORTS
Three black girls, ages 6, 8, and 9 years, had perioral or periocular eruptions of 6 months' duration. Each girl had been previously treated with nonfluorinated topical steroids without success. Examination revealed tiny, closely spaced, skin-colored papules around the mouth and eyes (Fig. 1). Biopsy specimens revealed. a dermal granulomatous infiltratesurrounded bylymphocytes with some predilection for the perifollicular dermis (Fig. 2). These nodular infiltrates contained pale-staining histiocytes that formed granulomas. Plasma cells were also present. Results of staining for acid-fast bacilli and fungi were negative. Polarized. light microscopy showed no evidence of foreign material. The histologic findings indicated a diagnosis ofthe granulomatous variant of perioral dermatitis. 847
848 Miller and Shalita
Journal of the American Academy of Dermatology November 1994
Fig. 2. Biopsy specimen of lesion reveals dermal granulomatous infiltrate surrounded by lymphocytes associated with pilosebaceous unit.
Fig. 3. After 14 weeks of treatment with metronidazole topical gel, 0.75%, there is marked resolution of lesions.
Treatment in these three patients was topical metronidazole gel, 0.75%, (MetroGel) twice daily. Significant improvement was observed after 2 months with 90% resolution of the lesions. Complete resolution occurred after 14 weeks (Fig. 3). All three patients tolerated the treatment well, and no atrophy or scarring was observed.
in this disease as well. Although previous authors have observed resolution of granulomatous perioral dermatitis without specific therapy, our results indicate that use of metronidazole gel may accelerate clearing.
DISCUSSION
REFERENCES
Topical metronidazole gel is widely used for the treatment of the inflammatory papules, pustules, and erythema of rosacea6 but its mechanism of action is not fully understood. Some of the proposed mechanisms include antiparasitic activity against Demodex folliculorum, suppression of bacterial skin flora, and an antiinflammatory effect by reduction of hydrogen peroxide and hydroxyl radicals. Because inflammatory lesions are also a primary feature of perioral dermatitis (and its granulomatous variant), it seems reasonable that treatment with topical metronidazole gel would be efficacious
I. Hogan DJ, Epstein JD, Lane PRo Perioral dermatitis: An uncommon condition? Can Med Assoc J 1986;134:1025-8. 2. Gianotti F, Ermacora E, Benelli M-G, et at. Particuliere dermatite perioral infantile: observations sur cing cas. Bull Soc Fr Dermatol Syph 1970;77:341. 3. Frieden Il, Prose NS, Fletcher Y, et al. Granulomatous perioral dermatitis in children. Arch Dermatol 1989;125: 369-73. 4. Marten RH, Presbury DG, Adamson JE, et al. An unusual papular and acneiform facial eruption in the negro child. Br J DermatoI1976;91:435-8. 5. Williams HC, Ashworth J, Pembroke AC, et at. FACEfacial Afro-Caribbean childhood eruption. Clin Exp DermatoI1990;15:163-6. 6. Bleicher PA, Charles JH, Sober AJ. Topical medronidizole therapy for rosacea. Arch Dermatol1987;123:609-14.
Fig. 1. Pretreatment photograph of pediatric perioral granulomatous dermatitis. tion)-to describe five cases of monomorphic papules with a central facial distribution. Two patients responded to treatment with oral erythromycin and in the other three patients lesions resolved spontaneously within 9 months. CASE REPORTS
Three black girls, ages 6, 8, and 9 years, had perioral or periocular eruptions of 6 months' duration. Each girl had been previously treated with nonfluorinated topical steroids without success. Examination revealed tiny, closely spaced, skin-colored papules around the mouth and eyes (Fig. 1). Biopsy specimens revealed. a dermal granulomatous infiltratesurrounded bylymphocytes with some predilection for the perifollicular dermis (Fig. 2). These nodular infiltrates contained pale-staining histiocytes that formed granulomas. Plasma cells were also present. Results of staining for acid-fast bacilli and fungi were negative. Polarized. light microscopy showed no evidence of foreign material. The histologic findings indicated a diagnosis ofthe granulomatous variant of perioral dermatitis. 847
848 Miller and Shalita
Journal of the American Academy of Dermatology November 1994
Fig. 2. Biopsy specimen of lesion reveals dermal granulomatous infiltrate surrounded by lymphocytes associated with pilosebaceous unit.
Fig. 3. After 14 weeks of treatment with metronidazole topical gel, 0.75%, there is marked resolution of lesions.
Treatment in these three patients was topical metronidazole gel, 0.75%, (MetroGel) twice daily. Significant improvement was observed after 2 months with 90% resolution of the lesions. Complete resolution occurred after 14 weeks (Fig. 3). All three patients tolerated the treatment well, and no atrophy or scarring was observed.
in this disease as well. Although previous authors have observed resolution of granulomatous perioral dermatitis without specific therapy, our results indicate that use of metronidazole gel may accelerate clearing.
DISCUSSION
REFERENCES
Topical metronidazole gel is widely used for the treatment of the inflammatory papules, pustules, and erythema of rosacea6 but its mechanism of action is not fully understood. Some of the proposed mechanisms include antiparasitic activity against Demodex folliculorum, suppression of bacterial skin flora, and an antiinflammatory effect by reduction of hydrogen peroxide and hydroxyl radicals. Because inflammatory lesions are also a primary feature of perioral dermatitis (and its granulomatous variant), it seems reasonable that treatment with topical metronidazole gel would be efficacious
I. Hogan DJ, Epstein JD, Lane PRo Perioral dermatitis: An uncommon condition? Can Med Assoc J 1986;134:1025-8. 2. Gianotti F, Ermacora E, Benelli M-G, et at. Particuliere dermatite perioral infantile: observations sur cing cas. Bull Soc Fr Dermatol Syph 1970;77:341. 3. Frieden Il, Prose NS, Fletcher Y, et al. Granulomatous perioral dermatitis in children. Arch Dermatol 1989;125: 369-73. 4. Marten RH, Presbury DG, Adamson JE, et al. An unusual papular and acneiform facial eruption in the negro child. Br J DermatoI1976;91:435-8. 5. Williams HC, Ashworth J, Pembroke AC, et at. FACEfacial Afro-Caribbean childhood eruption. Clin Exp DermatoI1990;15:163-6. 6. Bleicher PA, Charles JH, Sober AJ. Topical medronidizole therapy for rosacea. Arch Dermatol1987;123:609-14.