Is this perioral rash related to this girl's atopic dermatitis?
CASE: A 9-year-old girl with a history of atopic dermatitis and allergic rhinitis presented to our clinic with a one-month history of worsening perioral rash. The child was otherwise healthy, and she denied having had similar symptoms in the past. Treatment with over-the-counter moisturizers, barrier lotions, and hydrocortisone had only marginally improved the rash.
What is the cause of this patient’s condition?
(Answer and discussion on next page.)
ANSWER: This case demonstrates the classic presentation of irritant dermatitis—
specifically, lip-licker’s dermatitis.
Irritant contact dermatitis occurs secondary to the direct action of contacting substances such as soap, detergent, or, as with our case, saliva. Lip-licker’s dermatitis most commonly is seen in children who habitually lick their lips and who have a history of atopy or another cause of skin-barrier dysfunction. In lip-licker’s dermatitis, repetitive exposure to saliva removes the skin’s protective oils secreted by sebaceous glands and results in a characteristic perioral, inflammatory, eczematous rash that often involves the vermilion border. In severe cases, persistent lip licking may result in hyperpigmentation, scarring, or both in the affected area. The diagnosis is clinical, based on the patient’s history and presentation and, therefore, does not require biopsy or culture testing.
The differential diagnosis includes perioral dermatitis, allergic contact dermatitis, tinea faciei, impetigo, herpes simplex, and angular cheilitis. Perioral dermatitis, which also is often seen in patients with atopic dermatitis, is characterized by discrete inflammatory papules, pustules, or both that overly an erythematous base. Perioral dermatitis can occur in a perinasal, infraorbital, or perioral distribution, but it spares the vermilion border.
Allergic contact dermatitis is a pruritic, erythematous, and scaly condition of the skin that occurs in any area that demonstrates an inflammatory response to protein allergens or haptens. Allergy patch testing can be used in the diagnostic workup of suspected allergic contact dermatitis. Tinea faciei, more commonly known as ringworm, is a fungal skin infection characterized by pruritic, annular, erythematous, and well-demarcated lesions.
Impetigo, a superficial skin infection most commonly caused by Staphylococcus aureus and sometimes caused by group A β-hemolytic streptococci, is characterized by honey-colored, crusted lesions. Infection with herpesvirus most notably causes grouped vesicular lesions in the lips. Angular cheilitis occurs secondary to infection with Candida albicans or staphylococci, nutritional deficiency, or celiac disease. It is characterized by fissures and erythema at the corners of the mouth and is aggravated by lip licking.
Lip-licker’s dermatitis is a self-limited condition that resolves with avoidance of lip licking. Emollients can be used to lubricate the affected skin and to protect the skin barrier. In more severe cases, application of topical corticosteroids, such as 1% hydrocortisone ointment, may be useful to decrease local inflammation.
In our case, the parents’ consistent application of a barrier lubricant to the affected area, coupled with their having emphasized a “no licking” policy with their daughter, resulted in complete resolution of symptoms. Interestingly, during the next 6 months, various social and academic stressors triggered similar symptoms in the girl, with resolution of the condition after the stressor had ended.