Sniffing out the meaning of perialar intertrigo

By Warren R. Heymann, MD, FAAD
Jan. 4, 2023
Vol. 5, No. 1

The first sentence in the abstract by Sanchez et al intrigued me: “We observed isolated cases of perialar intertrigo in children and teenagers that did not appear to correspond to any known clinical entity.” They further state: “We describe a central facial cutaneous manifestation that has not been previously reported to our knowledge.” According to PubMed, they are correct — theirs is the only report of perialar intertrigo (PI). Despite its absence in the medical literature, I know I have seen this many times — could it be a disease sui generis or is it just a forme fruste of disorders we routinely encounter?

The authors conducted a prospective, multicenter cohort study including 41 patients. All were under 18 years of age (25 boys and 16 girls, average age: 12.1 years) with chronic PI (defined as erythema around the nasal alae for > 1 month). If possible, a Wood’s lamp examination of the intertrigo was performed. Initially, 71 patients were in the study, but exclusions included age limitation or the presence of well-defined facial dermatoses where perialar erythema could be observed (perioral dermatitis, rosacea, acne, or seborrheic dermatitis). PI was bilateral in 38 patients (93%). Most patients were asymptomatic (54%). Marked erythema and mild desquamation were present in all cases. Pruritus was present in 39% of patients. Orange-red follicular fluorescence was present in the perialar region on Wood’s light examination in 78% of cases with active fluorescence (the Wood’s light examination was performed in 29 patients). The presumptive diagnoses suggested by the investigators were acne (24.4%), seborrheic dermatitis (19.5%), rosacea (9.8%), psoriasis (9.8%), and perioral dermatitis (7.3%). No diagnosis was proposed in 22% of the cases. (1)

There is much to sort out about PI. Firstly, as the authors acknowledge themselves, “by excluding typical dermatoses with perialar involvement, we might have described mild cases of these dermatoses, limited to the perinasal folds.” (1) The etiology of PI is unknown, but if it is a forme fruste of other disorders, we should consider if known causative or aggravating factors of those entities are involved in PI. For perioral (or periorificial) dermatitis or rosacea, the use of topical steroids or fluorinated toothpaste may be at play. (2) Crisaborole may exacerbate pediatric periorificial dermatitis. (3) Demodex mites have long been associated with rosacea and perioral dermatitis. (2) Cutibacterium acnes plays a pathogenic role in acne inflammation (4) and Malassezia virulence factors (extracellular lipase, indoles, reactive oxygen species, lipoxygenase, azelaic acid, others) are implicated in seborrheic dermatitis, psoriasis, atopic dermatitis, and tinea versicolor. (5) It is conceivable that PI may be part of the spectrum of each of these disorders, which, of course, could direct therapeutic choices.

If there is no obvious clinical clue to one of the classically associated disorders of facial erythema, reasonable therapeutic options could include calcineurin inhibitors (tacrolimus and pimecrolimus, as these have been reported to be effective in pediatric periorificial dermatitis) (6,7), metronidazole, ivermectin, ketoconazole, clindamycin, and benzoyl peroxide. I would try to avoid topical steroids.

A few days after reading this article, a 52-year-old woman complained of an untreated, asymptomatic rash on the side of her nose that had been present for a couple of months (please see her photo). How timely. She had no evidence of rosacea, acne, seborrheic dermatitis, or psoriasis. I opted to prescribe ketoconazole. Obviously, PI is not limited to the pediatric population.

It is hard to reach any definitive conclusion about PI other than the fact that it is a real sign. Perhaps future studies will reveal unique characteristics of PI to qualify it as a separate entity. I thank Sanchez et al for putting a label on it and I agree with them; currently, PI is a sign — not a disease — that, in my estimation, is a forme fruste of disorders with which we are already familiar.

I asked several esteemed pediatric dermatology colleagues to provide their take on PI. I thank them for their viewpoints. Please read their thoughts.

Point to Remember: Perialar intertrigo (PI) may occur by itself, although it may accompany other disorders such as seborrheic dermatitis, acne, or periorificial dermatitis. Until research further clarifies this finding, consider PI a clinical sign rather than a distinct diagnosis.

Our experts’ viewpoints

Anna Bruckner, MD, MSCS, FAAD
Professor of Dermatology and Pediatrics
University of Colorado School of Medicine

The authors report a physical finding that is probably a clinical manifestation of many possibly etiologies, just as “classic” intertrigo can have many possible etiologies. I favor that this is an inflammatory reaction of sorts — it could be due to Cutibacterium acnes or other changes in the follicular microbiome that occur as kids enter puberty. To me, the features overlap with perioral dermatitis, seborrheic dermatitis, and irritant dermatitis. The authors felt the condition was not rosacea/perioral dermatitis because it did not respond to treatment, but there was such as range of treatments tried, it is impossible to make that conclusion. Because of the (suspected) multifactorial nature of this finding, it is difficult to recommend a uniform treatment approach. I would treat based on dominant lesional characteristics, possibly using a combination of medications such as metronidazole or clindamycin plus pimecrolimus. I would avoid vehicles that could overly dry or irritate pre-adolescent skin.

Mercedes E. Gonzalez, MD, FAAD
Clinical Assistant Professor of Dermatology
Florida International University Herbert Wertheim College of Medicine and University of Miami Miller School of Medicine

I agree with my pediatric dermatology colleagues on this one...I would not give this eruption yet another name. Our dermatology textbooks are already 2 volumes!

As Dr. Bruckner mentions, there are several possibilities when we see this clinical presentation, in my experience, it is most likely due to perioral dermatitis >>> seborrheic dermatitis > irritant contact dermatitis. The clinical images in Figure 1 of the paper, to me, appear like classic periorificial dermatitis! On clinical examination, if I am able to identify any papules or pustules (or if there is a history of these) I treat with PO azithromycin 10mg/kg/day three times a week x 4 weeks; that is usually enough to clear the eruption. If there is no history of papules or pustules, and it is mostly eczematous, I will prescribe pimecrolimus.

Moise L. Levy, MD, FAAD
Professor of Pediatrics and Medicine [Dermatology]
Dell Medical School, University of Texas at Austin

I find the study published by our colleagues in the September/October 2022 issue of Pediatric Dermatology on “Perialar intertrigo” to be well done and thought-provoking. I would assume that many of us caring for pediatric/adolescent patients have seen such patients and have wondered what to call it as well as what it might represent! I, for one, have felt this to be either a manifestation of seborrheic dermatitis or periorificial dermatitis (broadly stated). I believe that their data (and that of others) highlights the role of sebaceous gland activity. I believe that therapies, when felt to be necessary, should focus on that aspect of the condition. Personally, I have used tacrolimus or pimecrolimus in most cases unless there is more inflammation present as papules or pustules. I have no problem adding either metronidazole or clindamycin if the latter are present.

Howard B. Pride, MD, FAAD

The authors are to be congratulated for stimulating a great discussion. I am skeptical that perialar intertrigo is a distinct entity and even question “intertrigo” as an appropriate term for the condition, the skin folds lacking the moisture and friction so characteristic of intertrigo of the groin and abdomen. Their patients are familiar to us in pediatric dermatology and I believe represent various combinations of seborrheic dermatitis, periorificial dermatitis, irritant dermatitis, and perhaps demodex folliculitis who:

1. Are simply not responding well to correct therapy

2. Have the incorrect diagnosis and therefore treated with the incorrect medication leading to an altered presentation

3. Have multiple simultaneous diagnoses

I don’t find great value in labeling this a unique entity unless it leads to a specific intervention or an insight into pathogenesis. I don’t think either is accomplished here.

I think that a calcineurin inhibitor a good first-line treatment for these patients. 

Julie V. Schaffer, MD, FAAD
Professor of Pediatrics, Hackensack Meridian School of Medicine
Director, HUMC Pediatric Dermatology Fellowship

I agree that perialar intertrigo represents a clinical finding more than a distinct diagnostic entity. That said, it is a common presentation in pediatric patients that is worthy of recognition and discussion. I suspect that this likely represents a reaction pattern to resident microorganisms (e.g. Cutibacterium acnes, Malassezia, and Demodex) and frequently has overlapping features of seborrheic dermatitis (erythema and scale) and periorificial dermatitis (papular/papulopustular component). I therefore typically include a topical calcineurin inhibitor (which is helpful for both of these diagnoses) in the treatment regimen, with the addition of other agents such as a topical azole or topical ivermectin depending on the predominant or associated findings. Of note, I think that involvement of Demodex in facial eruptions in children, especially when there is a combination of papulopustules and scale, is often underrecognized. To quote Andrea Zaenglein: “Pustules on noses, think demodicosis!” (8)

1. Sanchez A, Mahe E, Miquel J, Abasq C, Phan A, Mazereeuw-Hautier J, Lemille J, Maruani A, Bonniaud B, Plantin P, Mallet S, Martin H, Hubiche T, Chiaverini C, Lacour JP; Groupe de Recherche de la Société Française de Dermatologie Pédiatrique. Perialar intertrigo in children and adolescents: A multicenter prospective study of 41 cases. Pediatr Dermatol. 2022 Sep;39(5):702-707. doi: 10.1111/pde.15036. Epub 2022 Jun 14. PMID: 35699273.

2. Tolaymat L, Hall MR. Perioral Dermatitis. 2022 Sep 5. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30247843.

3. Parker J, Neill B, Whitsitt J, Rajpara A, Aires D. Exacerbation of Pediatric Periorificial Dermatitis: A Novel Adverse Reaction. J Drugs Dermatol. 2020 Apr 1;19(4):428. PMID: 32401455.

4. Lam M, Hu A, Fleming P, Lynde CW. The Impact of Acne Treatment on Skin Bacterial Microbiota: A Systematic Review. J Cutan Med Surg. 2022 Jan-Feb;26(1):93-97. doi: 10.1177/12034754211037994. Epub 2021 Aug 15. PMID: 34396785; PMCID: PMC8750125.

5. Kurniadi I, Hendra Wijaya W, Timotius KH. Malassezia virulence factors and their role in dermatological disorders. Acta Dermatovenerol Alp Pannonica Adriat. 2022 Jun;31(2):65-70. PMID: 35751534.

6. Ollech A, Yousif R, Kruse L, Wagner A, Kenner-Bell B, Chamlin S, Yun D, Shen L, Vivar K, Reynolds M, Paller AS, Mancini AJ. Topical calcineurin inhibitors for pediatric periorificial dermatitis. J Am Acad Dermatol. 2020 Jun;82(6):1409-1414. doi: 10.1016/j.jaad.2020.01.064. Epub 2020 Feb 4. PMID: 32032693.

7. Lee H, Kim KH. Treatment of pediatric periorificial dermatitis with topical calcineurin inhibitor and topical/oral metronidazole. J Dermatol. 2021 Mar;48(3):405-407. doi: 10.1111/1346-8138.15695. Epub 2020 Dec 4. PMID: 33275294.

8. Douglas A, Zaenglein AL. A case series of demodicosis. Pediatr Dermatol. 2019;36:651-4.

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