Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2025;15(2):5239 1 Pediatric Perioral Dermatitis Associated with Inhaled Corticosteroids: A Retrospective Case Series Tullio Brunetti1,2, Marco Adriano Chessa1,2, Miriam Leuzzi1,2, Carlotta Gurioli1, Stephano Cedirian1,2, Iria Neri1 1 Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy 2 Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy Key words: Perioral Dermatitis, Inhaled Corticosteroids, Pediatric Patients, Drug-Related Side Effects, Retrospective Studies Citation: Brunetti T, Chessa MA, Leuzzi M, Gurioli C, Cedirian S, Neri I. Pediatric Perioral Dermatitis Associated with Inhaled Corticosteroids: A Retrospective Case Series. Dermatol Pract Concept. 2025;15(2):5239. DOI: https://doi.org/10.5826/dpc.1502a5239 Accepted: December 4, 2024; Published: April 2025 Copyright: ©2025 Brunetti et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: Neri I and Brunetti T coordinated and supervised data collection and critically reviewed and revised the manuscript for important intellectual content. Cedirian S, Chessa MA, Leuzzi M and Gurioli C conceptualized and designed the study and critically reviewed and revised the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Corresponding Author: Marco Adriano Chessa, Department of Dermatology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 1, 40138 Bologna, Italy. ORCID ID: Email: marcoadriano.chessa@gmail.com   Introduction A retrospective case series was conducted in 2023 at the Pedi- atric Dermatology Clinic at Sant’Orsola Malpighi University Hospital. Written consent for the scientific use of images was obtained from parents. The study adhered to the Declaration of Helsinki and received local ethic committee approval. Case Presentation Three patients were identified with perioral dermatitis (PD) following aerosol corticosteroid use. The average age was 3.3 years (range: 2-5). All patients used beclomethasone di- propionate aerosol via face mask for sore throats, none rins- ing the treated area, and manifested red micropapular and papulopustular lesions around the mouth, localized on the lower lip and chin (N=2) or in the nasolabial folds (N=1) after 5–7 days of aerosol withdrawal. Patients 1 and 3 used it twice daily for one week, and Patient 2 once daily for two weeks. Treatment of lesions involved either ivermectin 1% cream applied once daily (N=2) or metronidazole 1% gel applied twice daily (N=1) until complete resolution, with no recurrence observed at the 2-month follow-up. Complete data are provided in Table 1. Discussion PD is an inflammatory condition with erythematous micro- papules or papulopustules (Figure 1A) around the perioral area in children aged 7 months to 13 years. Its etiology is 2 Research Letter | Dermatol Pract Concept. 2025;15(2):5239 Table 1. Demographic, Clinical, and Therapeutic Information of Three Patients. Patient Number Age Comorbidities Aerosol Corticosteroid Treatment Information Prevalent Lesion Site of PD Treatment of PD Frequency of Application of PD Therapy Recurrence of PD After the Treatment 1 2 years Miliaria rubra Beclomethasone dipropionate in aerosol form via a face mask twice daily for 1 week before developing PD Nasolabial sulcus Topical ivermectin cream 1% Once daily None 2 3 years Neurofibromatosis type 1 Beclomethasone dipropionate in aerosol form via a face mask once daily for 2 weeks before developing PD Chin Topical metronidazole gel 1% Twice daily None 3 5 years Multiple small angiomas Beclomethasone dipropionate in aerosol form via a face mask twice daily for 1 week before developing PD Chin Topical Ivermectin cream 1% Once daily None Abbreviations: PD: perioral dermatitis. Figure 1. (A) Small erythematous papules or papulopustules. (B) Small and erythematous papules in the nasogenian sulcus, a common site for perioral dermatitis (PD). (C) Involvement of the chin area, an atypical localization of PD. (D) Close-up image demonstrating small erythematous papules characteristic of PD localized on the chin. Research Letter | Dermatol Pract Concept. 2025;15(2):5239 3 unclear, but it is strongly linked to systemic, inhaled, and topical steroid use. We observed an association between in- haled corticosteroid treatment and the onset of PD in three patients. Interestingly, lesions followed the mask’s contour on the face: Patient 1 had erythematous micropapules- papulopustules in the nasolabial sulcus, a common PD site (Figure 1B), while Patients 2 and 3 exhibited an involvement of the lower lip and chin with a distinct sharp termination at mentolabial fold, a rare presentation likely attributed to gravitational droplet pooling in the lower section of the mask (Figures 1C and 1D). Few studies have noted that PD occurred primarily in subjects who used a device equipped with a face mask or a nebulizer without a face mask or mouthpiece, and these findings corroborate with our study, reinforcing the hypothesis of a direct local effect of inhaled corticosteroids on facial skin [1,2]. Local side effects of in- haled corticosteroids in asthmatic children associated with age, drug, dose, and device have been reported. Among them, PD, although rarely described, affects 3% of young children, and its underreporting may be due to reports primarily from allergologists, pneumologists, and physicians, who do not focus on skin disorders [3]. Regarding lesion management, eliminating corticosteroids and potential skin irritants is essential and often sufficient for resolving mild dermatitis. However, topical therapies like ivermectin, metronidazole, or systemic erythromycin may also be needed [4]. Different studies consistently show that topical 1% ivermectin ad- ministered once daily has notable advantages over 0.75% metronidazole administered twice daily [5]. Based on com- parative analyses demonstrating superior outcomes and the convenience of a less frequent daily application, we prefer ivermectin. Conclusion Pediatricians must anticipate the potential onset of PD fol- lowing inhaled corticosteroid therapy and should educate parents on lesion progression, emphasize the importance of rinsing the perioral area, and consider discontinuing corti- costeroid therapy when appropriate, using suitable topical treatments. References 1. Dubus JC, Marguet C, Deschildre A, et al. Local side-effects of inhaled corticosteroids in asthmatic children: influence of drug, dose, age, and device. Allergy. 2001;56(10):944–8. DOI: 10.1034/j.1398-9995.2001.00100.x 2. Kumar P, Parashette KR, Noronha P. Letter: Perioral dermatitis in a child associated with an inhalation steroid. Dermatol Online J. 15 2010;16(4):13. DOI: 10.5070/D30tq4z5z9 3. Held E, Ottevanger V, Petersen CS, Weismann K. [Perioral der- matitis in children under steroid inhalation therapy]. Ugeskr Laeger. 17 1997;159(47):7002–3. PMID: 9417708 4. Schwarz T, Kreiselmaier I, Bieber T, et al. A randomized, double-blind, vehicle-controlled study of 1% pimecrolimus cream in adult patients with perioral dermatitis. J Am Acad Der- matol. 2008;59(1):34–40. DOI: 10.1016/j.jaad.2008.03.043 5. Taieb A, Khemis A, Ruzicka T, et al. Maintenance of remission following successful treatment of papulopustular rosacea with ivermectin 1% cream vs. metronidazole 0.75% cream: 36-week extension of the ATTRACT randomized study. J Eur Acad Der- matol Venereol. 2016;30(5):829–36. DOI: 10.1111/jdv.13537