Clinical characteristics and treatment outcomes of perioral dermatitis: a retrospective analysis using the PODSI score

Abstract

AimPerioral dermatitis (POD) is a common inflammatory facial dermatosis, yet real-world data integrating demographic characteristics, comorbidities, triggering factors, and objective severity scoring remain limited. This study aimed to evaluate the clinical features of POD and assess treatment outcomes using the Perioral Dermatitis Severity Index (PODSI). MethodsThis retrospective study included 34 patients with clinically confirmed POD and complete baseline and follow-up documentation. Demographic variables, disease duration, comorbid dermatologic conditions, triggering factors, and treatment modalities were recorded. Disease severity was quantified using PODSI at baseline and at the 4-week follow-up after treatment initiation. Statistical analyses included Wilcoxon signed-rank test, Spearman correlation, Mann–Whitney U test, and multivariable linear regression to identify predictors of treatment response. ResultsThe mean age was 26.7 years, and 85.3% of patients were female. The most common comorbidities were seborrheic dermatitis and rosacea. Combination therapies especially topical metronidazole with systemic antibiotics were frequently used. Mean baseline PODSI significantly decreased from 5.68 to 1.97 after treatment (P < .001). No significant associations were observed between PODSI scores and age, sex, disease duration, comorbidities, or triggers (all P > .26). Baseline PODSI was the only independent predictor of post-treatment severity (β = 0.59, P < .001). ConclusionSignificant improvement in PODSI scores was achieved across the cohort, independent of demographic factors or comorbidities. Baseline severity was the strongest predictor of treatment outcome, highlighting PODSI as a valuable tool for clinical monitoring.

Keywords

Introduction

Perioral dermatitis (POD) is an inflammatory facial dermatosis characterized by pruritic or tender erythematous papules, papulopustules, and fine scaling that predominantly affects the perioral region. It is most frequently observed in young women and has been associated with topical corticosteroid use, cosmetic products, epidermal barrier dysfunction, and microbial factors.^1-6 Although POD is a well-recognized clinical entity, its epidemiologic and clinical characteristics may vary across populations, and real-world data regarding patient demographics, disease duration, and treatment practices remain limited.
In routine clinical practice, assessment of disease severity is essential both for therapeutic decision-making and for monitoring treatment response. The Perioral Dermatitis Severity Index (PODSI) provides an objective method for quantifying clinical signs, allowing standardized evaluation of erythema, papules, and scaling.⁷ However, most available studies primarily focus on treatment efficacy, while comprehensive evaluations integrating demographic features and clinical severity are scarce. Therefore, the present study aimed to analyze the demographic and clinical characteristics of patients diagnosed with perioral dermatitis and to evaluate disease severity using the PODSI before and after treatment. Additionally, we aimed to describe treatment regimens applied in routine practice and to explore their distribution within the study population.

Materials and Methods

This retrospective observational study included 34 patients with clinically confirmed perioral dermatitis who had complete baseline and follow-up assessments available in their medical records. Since this was a retrospective study, no a priori sample size calculation was performed. All consecutive patients who met the inclusion criteria during the study period were included in the analysis. Demographic data, age at diagnosis, disease duration, comorbid dermatologic conditions, reported triggering factors, and current treatments were extracted from standardized clinical documentation. Clinical severity was evaluated using the PODSI, a validated objective scoring system based on three clinical parameters: erythema, papules, and scaling. Each component was graded on a scale from 0 to 3 in 0.5-point increments, resulting in a total score ranging from 0 to 9. Higher scores indicate greater disease severity. According to the original classification, total scores of 0.5–2.5 represent mild disease, 3.0–5.5 moderate disease, and 6.0–9.0 severe disease. Disease severity was assessed using the Perioral Dermatitis Severity Index (PODSI) at baseline and again 4 weeks after initiation of treatment. Triggering factors including topical corticosteroid exposure, inhaled corticosteroid exposure, and cosmetic product use were coded dichotomously, as were dermatologic comorbidities such as seborrheic dermatitis, rosacea, acne vulgaris and chronic urticaria. Treatment selection was based on the treating dermatologist's clinical judgment, taking into account disease severity, lesion distribution, previous treatment history, patient characteristics, and the presence of contraindications or intolerance to specific medications. In general, patients with milder disease were managed with topical therapies, whereas systemic treatment was preferred for patients with more extensive or persistent disease or those with an inadequate response to topical treatment. Ethical Approval This study was approved by the Bezmialem Vakıf University Institutional Ethics Committee (Date: 08.12.2025; Decision No: 221417). Statistical Analysis Statistical analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were summarized as mean ± standard deviation or median, while categorical variables were presented as counts and percentages. Normality was assessed using the Shapiro–Wilk test, and pre- to post-treatment comparisons were performed using the Wilcoxon signed-rank test. Associations between continuous variables were evaluated using Spearman correlation analysis, and group differences by sex, comorbidities, and triggers were analyzed using the Mann–Whitney U test. To identify independent predictors of treatment outcome, a multivariable linear regression model was constructed with post-treatment PODSI score as the dependent variable and baseline PODSI score, age, and disease duration as independent variables selected based on their clinical relevance. Standardized regression coefficients (β) were reported, and statistical significance was defined as P < .05. Reporting GuidelinesThis study was reported in accordance with the STROBE guideline.

Results

The demographic and baseline clinical characteristics of the study group are summarized in Table 1. A total of 34 patients were included in the study, with a mean age of 26.7 ± 17.0 years and a median disease duration of 5.5 weeks (range: 1–156). The mean age at diagnosis was 25.9 ± 16.8 years. Female patients constituted 85.3% of the study population, whereas male patients accounted for 14.7%. The most frequent comorbid dermatologic conditions were seborrheic dermatitis (20.6%) and rosacea (20.6%), followed by tinea infection (8.8%), chronic urticaria (5.9%), and acne vulgaris (2.9%). Regarding treatment regimens, 7 patients (20.6%) received topical metronidazole monotherapy, 5 (14.7%) received topical erythromycin monotherapy, and 5 (14.7%) were treated with topical calcineurin inhibitors alone. Combination therapies were common: 4 patients (11.8%) received topical metronidazole combined with topical calcineurin inhibitors, 8 patients (23.5%) received topical metronidazole plus systemic antibiotics, and 5 patients (14.7%) received topical calcineurin inhibitors combined with systemic antibiotics. The mean baseline PODSI score was 5.68 ± 1.55, which significantly decreased to 1.97 ± 1.16 after treatment (P < .001). Each clinical component—erythema, papules, and scaling—showed marked improvement following therapy (all P < .001). Spearman correlation analyses revealed no significant associations between baseline or post-treatment PODSI scores and age, age at diagnosis, or disease duration (all P > .28). Likewise, comparisons by sex demonstrated no significant differences in either baseline severity or treatment response (all P > .57). The presence of seborrheic dermatitis or rosacea also did not influence PODSI scores or clinical improvement (all P > .52). Triggering factors, including topical corticosteroid exposure (32.4%), inhaled corticosteroids (2.9%), and cosmetic products (2.9%), showed no significant association with baseline PODSI severity or the magnitude of PODSI reduction (all P > .26). In multivariable linear regression analysis, baseline PODSI score emerged as the only independent predictor of post-treatment PODSI (β = 0.59, P < .001), while age and disease duration were not significant contributors (P = .83 and P = .061, respectively). Overall, the cohort demonstrated a robust treatment response, and neither demographic factors, comorbid dermatoses, nor reported triggers appeared to significantly influence clinical severity or therapeutic outcomes; rather, treatment results were chiefly determined by the initial disease burden.

Discussion

In this retrospective cohort of 34 patients with POD, we observed a marked female predominance (85.3%) and a relatively young mean age (26.7 years), with moderate baseline disease severity as reflected by a mean PODSI score of 5.68. Significant clinical improvement was achieved across all PODSI components following treatment, with a substantial reduction in total scores (mean 1.97 post-treatment, P < .001). Combination regimens were frequently utilized in routine practice, particularly topical metronidazole with systemic antibiotics. Multivariable analysis demonstrated that baseline disease severity was the only independent predictor of post-treatment outcome, while demographic variables, comorbid dermatoses, and reported triggering factors did not significantly influence treatment response. Our demographic findings are consistent with previously published epidemiologic data indicating that POD predominantly affects women in early to middle adulthood. Large population-based studies have demonstrated higher incidence and prevalence rates among women, particularly those between 30 and 40 years of age.^8,9 Although our cohort appears somewhat younger, this difference may reflect referral patterns, local demographic characteristics, or inclusion of adolescent patients. Nevertheless, the strong female predominance observed in our study aligns closely with existing literature. Topical corticosteroid exposure was identified in approximately one-third of our cohort, yet it was not associated with increased baseline severity or poorer treatment response. Corticosteroid use is widely regarded as a trigger rather than a severity determinant. The comprehensive review by Tempark and Shwayder highlights topical corticosteroids as a common precipitating factor but emphasizes uncertainty regarding their precise pathogenetic role.¹⁰ Interestingly, in the randomized controlled trial of pimecrolimus cream, patients with corticosteroid-induced POD showed particularly strong therapeutic benefit, suggesting that once inflammation is established, anti-inflammatory strategies may override the initial trigger effect.¹¹ Our data support the concept that steroid exposure may initiate disease but does not necessarily predict worse short-term outcomes when appropriate therapy is initiated. With regard to therapeutic strategies, oral tetracyclines have historically been supported by the strongest clinical evidence.^12,13 In our cohort, oral tetracyclines were frequently combined with topical agents in moderate to severe cases. Emerging approaches have explored targeted therapies such as topical ivermectin or narrow-spectrum tetracyclines in an effort to maintain efficacy while minimizing antibiotic resistance.¹⁴ Although our study was not designed to compare specific regimens, the significant reduction in PODSI scores across treatment groups underscores the effectiveness of multimodal management in moderate disease. The frequent use of combination therapy in our population likely reflects clinicians’ preference for rapid disease control in patients presenting with higher baseline severity. Topical calcineurin inhibitors represent an important steroid-sparing option in POD management. Randomized controlled data have demonstrated that pimecrolimus significantly improves POD severity compared to vehicle, particularly in corticosteroid-induced cases.¹¹ Additionally, case reports and smaller studies suggest that tacrolimus may be beneficial in selected patients, including pediatric populations.¹⁵ In our study, calcineurin inhibitors were used both as monotherapy and in combination regimens, supporting their role as effective anti-inflammatory agents in sensitive facial areas. Microbial factors, including altered skin microbiota and increased Demodex density, have been increasingly implicated in the pathogenesis of POD.³ Anti-inflammatory and antiparasitic agents such as ivermectin may therefore offer therapeutic benefit beyond conventional antibiotics. Although we did not assess microbial colonization and efficacy of topical ivermectin in our cohort, the consistent clinical improvement observed suggests that modulation of cutaneous inflammation remains central to successful management. Importantly, baseline PODSI score emerged as the sole independent predictor of post-treatment severity in our regression analysis. This observation suggests that initial inflammatory burden may be the most clinically meaningful determinant of short-term outcome, rather than demographic characteristics, comorbid dermatoses, or reported triggers. These findings emphasize the importance of early recognition and objective severity assessment to guide treatment intensity and follow-up planning.

Limitations

This study has several limitations. First, its retrospective and single-center design may limit the generalizability of the findings and introduce the possibility of selection bias. Second, the heterogeneous treatment groups reflect real-world clinical practice but may have influenced treatment outcomes and limited direct comparisons between treatment modalities. In addition, treatment selection was based on the treating physician's clinical judgment rather than a standardized treatment protocol, introducing potential variability in therapeutic approaches. As with all retrospective studies, incomplete or missing data may also have affected the analyses. Nevertheless, this study provides valuable real-world data on the clinical characteristics and short-term treatment outcomes of patients with perioral dermatitis evaluated using the PODSI scoring system.

Conclusion

In conclusion, this study provides a comprehensive clinical overview of patients diagnosed with perioral dermatitis, highlighting their demographic characteristics, disease severity, and treatment patterns. The cohort consisted predominantly of female patients, and combination therapies were frequently used in routine practice. Significant improvement was observed in all clinical parameters, including PODSI scores, following treatment. While baseline disease severity was the strongest predictor of post-treatment outcomes, demographic variables did not significantly influence treatment response. These findings support the utility of PODSI as an objective tool for monitoring disease activity while also emphasizing the importance of evaluating patient characteristics and therapeutic approaches. Further prospective studies with larger cohorts are warranted to better define predictors of treatment response and optimize management strategies in perioral dermatitis.

Declarations

Abbreviations

References

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