Periocular hyperpigmentation: a review of etiology and current treatment options.

BACKGROUND: Periocular "dark circles" fall among the most difficult chief complaints to address. In most cases, we have little information regarding etiology and no gold-standard treatment option. The extent of the problem is reflected in the sheer number of products on the market advertised to either lighten or cover the pigmentation. OBJECTIVE/METHODS: To present dermatologists with a complete review of the literature with regard to anatomy, definition, etiology, and treatment of periocular hyperpigmentation. CONCLUSIONS: Our understanding of the causes and treatment of periocular hyperpigmentation continues to advance. Nevertheless, we are in need of additional controlled clinical trials and novel therapeutic options. Individual patients will likely benefit most from a combination of approaches. Although more randomized clinical studies are necessary, Pfaffia paniculata/Ptychopetalum olacoides B./Lilium candidum L.-associated compound cream seems to be a promising option, with 90% improvement. For patients with increased melanin deposition, quality-switched ruby laser therapy could offer a better treatment option. In the hands of experienced professionals, a surgical option might be suitable, either by autologous fat transplantation or hyaluronic acid filler.

Periorificial dermatitis due to systemic corticosteroids in children: report of two cases.

Periorificial dermatitis is a common acneiform eruption that is thought to represent a variant of rosacea. These patients typically present with uniform erythematous papules most commonly located periorally but also occurring around the nose and eyelids. This eruption has been linked to topical corticosteroid use, with only a few reports in the literature associated with systemic steroid use in adults. Here, we report two cases of periorificial dermatitis occurring after systemic corticosteroid use in children.

Perioral dermatitis: Diagnosis, proposed etiologies, and management.

BACKGROUND AND AIMS: Perioral dermatitis is a common cutaneous condition characterized by acneiform facial eruptions often with an eczematous appearance. A granulomatous subtype exists in addition to the classic variant. While topical corticosteroids have been largely implicated in this condition, its etiology is not completely understood. METHODS: Using the keywords "corticosteroids," "dermatology," "fusobacteria," "perioral dermatitis," and "periorificial dermatitis," we searched the databases PubMed, MEDLINE, and EMBASE to find the relevant literature. Only articles in English were chosen. The level of evidence was evaluated and selected according to the highest level working our way downwards using the Oxford Centre of Evidence-Based Medicine 2011 guidance. RESULTS: This systematic review found the strongest evidence to support topical corticosteroid misuse as the principal causative factor in the pathogenesis of perioral dermatitis. CONCLUSION: In terms of treatment, further research is required to robustly investigate promising treatment options including tetracyclines, topical metronidazole, topical azelaic acid, adapalene gel, and oral isotretinoin.

Steroid-induced periorificial dermatitis in children--clinical features and response to azelaic acid.

Periorificial dermatitis, a common skin disease in young women, has been occasionally reported in children. This study elaborates the clinical features of periorificial dermatitis in children as well as possible pathogenetic factors and the response to 20% azelaic acid cream. A total of 10 children aged 3 to 12 (mean 7.7) years suffering from nongranulomatous periorificial dermatitis for 3 to 7 (mean 4.9) months were evaluated, and dermatologic examination was carried out. Pretreatment was documented. Skin prick tests with a panel of six common inhalative allergens and patch tests with the European Standard Series were performed. An association between atopy and periorificial dermatitis was evaluated, and patients were screened for skin colonization by fungi, bacteria, and Demodex mites. They were treated with 20% azelaic acid cream, which was topically applied twice daily on all affected areas, until complete resolution was achieved. Treatment period was followed by an individual observation period. Periorificial dermatitis had developed in typical distribution and morphology. In all patients, low- to high-potency topical corticosteroids had been used on the face prior to manifestation. Atopy was found in half of the patients. Allergological, bacteriological, and mycological examinations did not reveal pathologic results. Demodex mites could not be demonstrated by skin surface biopsy. Treatment with 20% azelaic acid cream led to complete resolution of skin lesions after 4 to 8 (mean 5.4) weeks in all patients. Transient exacerbation of skin condition with a peak between the 2nd and 6th day of treatment could be observed in three patients. Side effects of 20% azelaic acid cream were registered in six patients and were predominantly present in the first 2 weeks of treatment. Side effects were minimal and became rarer with ongoing treatment. No recurrences were seen within a follow-up period of 2 to 8 (mean 4.4) months. Treatment with 20% azelaic acid cream could provide an effective and safe alternative therapeutic option in children with nongranulomatous periorificial dermatitis.

Symptomatic acquired zinc deficiency in at-risk premature infants: high dose preventive supplementation is necessary.

Zinc is a cofactor for several enzymes involved in many metabolisms. Zinc deficiency induces various disorders such as acrodermatitis enteropathica, either inherited or acquired. We report three cases of premature infants (24-31 wks gestational age) with low birthweight (650 to 940 g) and enteropathy, two of whom presented with necrotizing enterocolitis. All infants were fed by total parenteral nutrition. At a chronological age ranging from 73 to 80 days, all infants developed a periorificial dermatitis. Before the onset of the first signs, they had received zinc supplementation ranging from 146% to 195% of the recommended dose (400 microg/kg/day). Increased zinc supplementation over a course of 6-18 days induced a complete resolution of symptoms in all cases. No abnormality in the neurologic examination and no recurrence were observed at the end of the zinc treatment. Low birthweight premature infants with enteropathy on total parenteral nutrition are at risk of developing zinc deficiency. The usual recommended zinc supplementation is probably insufficient for those infants. A delay in the diagnosis of zinc deficiency may lead to severe complications.

Circumocular exanthema associated with chronic rejection after kidney transplantation.

A 43-year-old man had severe circumocular exanthema associated with chronic rejection 10 years after receiving a kidney transplant to treat end-stage renal failure. After the renal allograft was extracted, the exanthema diminished rapidly without any treatment. Donor-reactive immune cells seem to have cross-reacted with unknown pathogens on the skin and contributed to inflammation.

Periorbital dermatitis: causes, differential diagnoses and therapy.

Periorbital dermatitis is common and frequently difficult to treat. Patients with periorbital dermatitis often suffer severely because their disease is in such a visible location. Because of the variety of clinical appearance, the differential diagnostic considerations are often difficult. We examined the causes of periorbital dermatitis and compared the data of 88 patients from the Department of Dermatology, University Hospital Erlangen to those of the German IVDK (Information Network of the Departments of Dermatology). Between 1999 and 2004, predominant causes of periorbital dermatitis were allergic contact dermatitis (Erlangen 44%, IVDK 32%), atopic eczema (Erlangen 25%, IVDK 14%), airborne contact dermatitis (Erlangen 10%, IVDK 2%) and irritant contact dermatitis (Erlangen 9%, IVDK 8%). Less frequent causes for secondary eczematous periocular skin lesions were periorbital rosacea, allergic conjunctivitis or psoriasis vulgaris. Female gender, atopic skin diathesis and age of 40 years and older were identified as risk factors for periocular dermatitis. Common elicitors of periorbital allergic contact dermatitis were leave-on cosmetic products (face cream, eye shadow) and eye drops with the usual allergens being fragrances, preservatives and drugs. Exact identification of relevant contact allergens and allergen elimination are essential for successful treatment. Calcineurin inhibitors are the first-line therapy for facial atopic eczema. They may be also effective in periocular eczematous lesions of other origins although they are not approved for such use.

Oral Granulomatous Disease.

Granulomatous diseases are chronic inflammatory disorders whose pathogenesis is triggered by an array of infectious and noninfectious agents, and may be localized or a manifestation of systemic, disseminated disease. As in the skin, oral manifestations of granulomatous inflammation are often nonspecific in their clinical appearance. Thus, in the absence of overt foreign material or a recognizable infectious agent, identifying the underlying cause of the inflammation can be challenging. This article highlights various conditions known to induce granulomatous inflammation within the oral soft tissues.

Cutaneous normolipemic plane xanthoma with supraglottic involvement in a patient with hand-Schüller-Christian Disease: a case report.

Normolipemic plane xanthoma (NPX) is a histiocytic disorder characterized by yellow-orange plaques in the periorbital areas, neck, upper trunk, and flexural folds. Association with systemic disease or paraproteinemia has been reported previously, but rarely with Langerhans cell histiocytosis (LCH). We report a case of Hand-Schüller-Christian disease (a type of LCH) in a patient who developed NPX with supraglottic involvement. NPX developed after several courses of chemotherapy and the supraglottic xanthoma occurred about 2 years later. The coexistence of LCH and non-LCH histiocytic lesions in this patient could be a result of chemotherapy-induced changes or may be just coincidental.

Periocular dermatitis: a report of 401 patients.

BACKGROUND: Periocular contact dermatitis may appear as contact conjunctivitis, contact allergic and/or irritative eyelid and periorbital dermatitis, or a combination of these symptoms. The clinical symptoms may be induced by several environmental and therapeutic contact allergens. OBJECTIVES: The aim of the present study was to map the eliciting contact allergens in 401 patients with periocular dermatitis (PD) by patch testing with environmental and ophthalmic contact allergens. METHODS: Following the methodics of international requirements, 401 patients were tested with contact allergens of the standard environmental series, 133 of 401 patients with the Brial ophthalmic basic and supplementary series as well. RESULTS: Contact hypersensitivity was detected in 34.4% of the patients. Highest prevalence was seen in cases of PD without other symptoms (51.18%), in patients of PD associated with ophthalmic complaints (OC; 30.4%), and PD associated with atopic dermatitis (AD; 27.9%). In the subgroup of PD associated with seborrhoea (S) and rosacea (R), contact hypersensitivity was confirmed in 17.6%. Most frequent sensitisers were nickel sulphate (in 8.9% of the tested 401 patients), fragrance mix I (4.5%), balsam of Peru (4.0%), paraphenylendiamine (PPD) (3.7%), and thiomersal (3.5%). By testing ophthalmic allergens, contact hypersensitivity was observed in nine patients (6.7% of the tested 133 patients). The most common confirmed ophthalmic allergens were cocamidopropyl betaine, idoxuridine, phenylephrine hydrochloride, Na chromoglycinate, and papaine. LIMITATIONS: Patients with symptoms of PD were tested from 1996 to 2006. CONCLUSIONS: The occurence of contact hypersensitivity in PD patients was in present study 34.4%. A relatively high occurrence was seen in cases of PD without other symptoms, in PD + OC and in PD + AD patients. The predominance of environmental contact allergens was remarkable: most frequent sensitizers were nickel sulphate, fragrance mix I, balsam of Peru, thiomersal, and PPD. The prevalence of contact hypersensitivity to ophthalmic allergens did not exceed l.5%.

Perioral dermatitis after dental filling in a 12-year-old girl: involvement of cholinergic system in skin neuroinflammation?

The etiopathogenesis of perioral dermatitis (PD) is still unknown and, consequently, medical treatment is difficult, not precisely defined, and often unsatisfactory. On the basis of a peculiar case that appeared soon after multiple dental fillings with a mercury-containing amalgam, we proposed that neurogenic inflammation could play a role in the pathogenesis of PD. According to the new findings provided by clinical and basic research, neurogenic inflammation has a relevant part in the pathogenesis of many cutaneous diseases. We report a similar case of PD, taking into account, more specifically, the possible involvement of the cholinergic system. Also in this case, PD seems to be mainly related to the mercury contained in dental fillings and/or its organic compounds formed by oral/gut bacteria. We examined the possible role of these substances as causes of PD, providing new information on the possible cross-talk between neuroimmunodermatology and potential triggers of PD.

Perioral dermatitis.

Perioral dermatitis is an inflammatory facial skin disorder that predominantly affects women. It is rarely diagnosed in children. The etiology of perioral dermatitis is unknown; however, uncritical use of topical corticosteroids often precedes skin lesions. There is a written diagnostic work-up, differential diagnosis and treatment.

Inflammatory and glandular skin disease in pregnancy.

A switch from cell-mediated to humoral immunity (helper T 1 [Th1] to helper T 2 [Th2] shift) during gestation plays a key role in placental immune tolerance. As a result, skin diseases that are Th2 mediated often worsen, whereas skin diseases that are Th1 mediated often improve during gestation. Also, due to fluctuations in glandular activity, skin diseases involving sebaceous and eccrine glands may flare, whereas those involving apocrine glands may improve during pregnancy. Despite these trends, inflammatory and glandular skin diseases do not always follow the predicted pattern, and courses are often diverse. We review the gestational course of inflammatory skin diseases, such as atopic dermatitis (atopic eruption of pregnancy), psoriasis, impetigo herpetiformis, urticaria, erythema annulare centrifugum, pityriasis rosea, sarcoidosis, Sweet syndrome, and erythema nodosum, as well as glandular skin diseases, including acne vulgaris, acne rosacea, perioral dermatitis, hidradenitis suppurativa, Fox-Fordyce disease, hyperhidrosis, and miliaria. For each of these diseases, we discuss the pathogenesis, clinical presentation, and management with special consideration for maternal and fetal safety.

Allergic contact dermatitis: Kids are not just little people.

Over the last ten years, there has been an increased awareness of allergic contact dermatitis (ACD) in children, in addition to adults. Historically, ACD was not considered a significant disease in the pediatric population. This may have been due to failure to employ patch testing, which is the gold standard for establishing a diagnosis of ACD. A number of epidemiologic studies now reflect upon the significance of positive patch tests in children and its utility in diagnosing ACD. While there is significant overlap among the most common allergens in children and adults, the patterns of exposure and sources of allergens can significantly differ, because children have distinct experiences related to their exposure to personal care products, articles of clothing, and time spent in play as opposed to work. Evaluation of the pediatric patient with dermatitis involves specialized knowledge in taking the pediatric history and specific techniques employed for successful patch test application.

Skin manifestation of methylmalonic acidemia: case report and review of the literature.

Skin manifestations, including scalded skin, desquamation, and chronic periorificial dermatitis, are rare clinical signs in patients with methylmalonic acidemia. This condition may be due to enzyme deficiency or multi-nutrient deficiency because of nutritional restriction. Bullous skin lesion is very rare in these patients and consequently, this type of skin lesion can be the presenting sign of methylmalonic acidemia.

Granulomatous Rosacea and Periorificial Dermatitis: Controversies and Review of Management and Treatment.

Granulomatous rosacea and periorificial dermatitis are common skin conditions affecting the face. This article examines the historical origin, causes, clinical presentation, and management strategies for these entities.