Canine Perioral Dermatitis

Jennifer Schissler Pendergraft, DVM, MS, DACVD, Colorado State University

ArticleHandoutLast Updated August 20136 min readPeer Reviewed
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  • Perioral dermatitis (PD) is inflammation of the maxillary or mandibular cutaneous or mucocutaneous tissues.

  • PD has diverse clinical presentations and causes and may be noted as a singular clinical entity or among generalized dermatologic or systemic signs.


  • PD is not limited to lip fold intertrigo (ie, bacterial and Malassezia spp overgrowth; Figure 1); rather, it is a potential manifestation of focal or generalized cutaneous conditions.

    • Conditions include hypersensitivities, immune-mediated dermatopathy, infection, hepatopathy, periodontal disease, and neoplasia.  

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Figure 1

Lip fold intertrigo in a dog

Signalment & Causes

  • See Handout: Causes of Perioral Dermatitis for causes and presentations.

    • Some causes have known breed and age associations.

Risk Factors

  • Redundant lip folds can predispose patients to intertrigo.

    • Any primary cause of PD poses risk for secondary bacterial or Malassezia spp infection.

  • Chronic use of topical or systemic glucocorticoids poses risk for demodicosis.

  • Sun exposure can pose a risk for pemphigus foliaceus and discoid lupus erythematosus (Figure 2).

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Figure 2

Discoid lupus erythematosus in a dog


  • Cutaneous or mucocutaneous inflammation can occur from causes that prompt erythema, pruritus, and primary lesions (eg, papules, pustules, vesicles, bullae), followed by secondary lesions (eg, erosions, ulcerations, crusts, alopecia).

    • The resulting skin barrier disruption predisposes patients to secondary bacterial and Malassezia spp overgrowth.

  • The microenvironment of a deep, redundant lip fold predisposes patients to intertrigo.

  • Severe periodontal disease with ptyalism may predispose to secondary perioral infection, particularly with deep lip folds.

  • Pruritus and malodor are common.


  • Signalment and clinical signs should be noted and history recorded:

    • Degree, location, and seasonality of pruritus

    • Duration and progression of lesions

    • Previous treatments and response

    • Dietary history

Physical Examination

  • Cutaneous examination (eg, of the footpads, interdigital spaces, and nasal planum) should be completed.

  • Otoscopic and ophthalmic examinations should be performed.

  • The oral cavity, mucous membranes, and mucocutaneous junctions should be examined.

  • Lymphadenopathy should be assessed and lymph nodes palpated.


Definitive Diagnosis

  • Definitive diagnosis is achieved via history, examination, and appropriate diagnostics.

  • Secondary infections should be resolved, as they can confound clinical and histopathologic features of the primary cause.

  • Histopathology is required for diagnosis of immune-mediated disease, superficial necrolytic dermatitis, zinc-responsive dermatitis (Figure 3), and cutaneous epitheliotropic lymphoma (Figure 4).

  • Patients with nonseasonal perioral pruritus may require an 8-week prescription or home-cooked elimination diet to differentiate atopic dermatitis (Figure 5) from cutaneous adverse food reaction (CAFR).

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Figure 3

Zinc-responsive dermatitis in a dog

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Figure 4

Cutaneous epitheliotropic lymphoma in various canine patients

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Figure 5

Atopic lip fold dermatitis with cheilitis and secondary Staphylococcus spp infection


  • Acetate tape preparation (only for dry lesions) and impression smear of exudates should be performed to assess for bacteria, Malassezia spp, and presence of acantholytic keratinocytes.

Fine-Needle Aspiration

  • Nodules and enlarged lymph nodes should be aspirated.

Deep Skin Scrape

  • Deep skin scrape or pluck for Demodex spp (Figure 6) should be performed in all cases.

    • If patient compliance impedes the performance of a deep skin scrape, several representative areas (~100 hairs per sample) can be plucked and examined with mineral oil and a coverslip.1

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Figure 6

Perioral and facial demodicosis in a dog


  • Dermatophyte culture is indicated if lesions are consistent (see Handout: Causes of Perioral Dermatitis) and secondary infection and Demodex spp have been ruled out.

  • Bacterial culture is indicated if clinical and cytologic response to antimicrobial therapy is lacking.

  • Culture nodular or ulcerative lesions if bacteria are found on cytology; culture superficial lesions if intracellular rods are found.

Elimination Diet Trial

  • A strict novel or hydrolyzed diet or home-cooked novel diet should be prescribed for a minimum of 8 weeks to differentiate CAFR from nonseasonal atopic dermatitis.

    • Diet should be rechallenged to confirm the diagnosis.


  • Vesiculobullous presentations (Figure 7) and lesions that remain after resolution of secondary infection should undergo biopsy.

    • Multiple lesions representing all stages of disease should be sampled.

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Figure 7

Mucous membrane pemphigoid in a dog

Additional Diagnostics

  • Serum biochemistry profile and abdominal ultrasonography are recommended to support diagnosis of superficial necrolytic dermatitis.

  • CBC, serum biochemistry profile, fecal flotation, and urinalysis are recommended in cases of adult-onset generalized demodicosis to screen for underlying systemic disease. 


Lip Fold Intertrigo

  • Daily use of topical antiseptic and drying agents should be initiated.

    • 2% acetic acid, 2% boric acid, and antimicrobial-based wipes and solutions are appropriate for maintenance therapy.

  • Acid- and alcohol-based topical medications are not recommended for erosive or ulcerative lesions.

    • If erosions, ulcers, crusts, nodules, or depigmentation are present, systemic antimicrobial therapy is indicated (see Bacterial Infection & Mucocutaneous Pyoderma).

  • Cheiloplasty is curative in patients that have lip fold intertrigo (with no other underlying cause) and are refractory to maintenance therapy.

Bacterial Infection & Mucocutaneous Pyoderma

  • Topical therapy is recommended in all cases.

  • Systemic antimicrobial therapy is recommended for erosive or ulcerative, crusting, and depigmentation presentations.

  • If cocci are found on cytology, appropriate empirical choices include:

    • Clindamycin at 11 mg/kg PO q12–24h

    • Cephalexin at 22–30 mg/kg PO q12h

    • Cefpodoxime at 5–10 mg/kg PO q24h

    • Cefovecin at 8 mg/kg SC q14d up to 2–3 times

    • Amoxicillin–clavulanate at 13.75 mg/kg PO q12h

  • Solutions and wipes containing 2% acetic acid, 2% boric acid, or 2%–4% chlorhexidine may be used daily and maintained q3–7d after resolution.

  • Avoid acid or alcohol-containing products if erosions are present.

  • Shampoos containing 2.5% benzoyl peroxide or 2%–4% chlorhexidine may be used 2–3 times weekly.

  • For mixed infections and ulcerative lesions, silver sulfadiazine cream should be considered.

  • Mupirocin ointment is most appropriate for methicillin-resistant Staphylococcus spp infections.

Malassezia spp Infection

  • These infections should be treated topically.

  • Solutions and wipes containing 2% acetic acid, 2% boric acid, 2%–4% chlorhexidine, 2% miconazole, or 1%–2% ketoconazole may be used q24–48h until resolved, then maintained 1–2 times weekly.

  • Focal, dry presentations should be treated with daily applications of ointments with 1% clotrimazole, 1%–2% miconazole, 1% terbinafine, 4% thiabendazole, or nystatin.

  • Shampoos with 1%–2% ketoconazole, 2% miconazole, 2%–4% chlorhexidine, or 2.5% benzoyl peroxide may be used 2–3 times weekly.

  • Adjunct systemic therapy for generalized or severe multifocal presentations should be initiated:

    • Ketoconazole at 5–10 mg/kg PO q24h

    • Itraconazole at 5–10 mg/kg PO q24h

    • Fluconazole at 10 mg/kg PO q24h

    • Terbinafine at 30 mg/kg PO q24h


  • These infections should be treated systemically and topically (see Malassezia spp Infection).

    • Lime sulfur may be used for generalized presentations.

Immune-Mediated Conditions*

  • Mild focal presentations may be managed with 0.1% topical tacrolimus (Protopic) and/or doxycycline and niacinamide.

  • Typically severe presentations initially require prednisolone at 2 mg/kg q24h.

    • A secondary immunomodulator may be administered as a steroid-sparing agent or to ach­ieve remission.

      • Immunomodulating agents include azathioprine, cyclosporine A, mycophenolate, and chlorambucil.

      • Diagnosis, condition severity, and potential adverse effects will influence treatment choices.

  • Juvenile cellulitis (Figure 8) is treated with prednisolone as sole therapy.

  • For mild cutaneous drug eruptions, discontinuation of the drug alone may be sufficient.

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Figure 8

Juvenile cellulitis in a dog


  • No treatment is required or reliably effective.

Focal Demodicosis

  • Treatment is not recommended; lesions are expected to resolve within 4–8 weeks.

Generalized Demodicosis

  • Treatment options include:

    • Amitraz dips q14d

    • Ivermectin at 0.3–0.6 mg/kg PO q24h

    • Milbemycin oxime at 1–2 mg/kg PO q24h

    • Doramectin at 0.6 mg/kg PO or SC q7d2

    • Topical 10% imidacloprid and 2.5% moxidectin q7–14d3 (off label)

Epitheliotropic Lymphoma*

  • Therapies include prednisolone as well as oral, injectable, and topical chemotherapeutic agents.

  • Consultation with a veterinary oncologist is recommended.

Superficial Necrolytic Dermatitis

  • Treatment includes topical antimicrobial therapy and IV and/or oral amino acid supplementation to manage dermatologic lesions.

  • Hepatopathy is treated symptomatically, and surgery or octreotide may be considered for pancreatic glucagonoma.4

  • Prognosis for survival is poor to grave.

Zinc-Responsive Dermatosis

  • Lifelong supplementation with zinc gluconate at 5 mg/kg PO q24h, zinc sulfate at 10–15 mg/kg PO q24h, or zinc methionine at 1.7 mg/kg PO q24h is required; additional topical or oral glucocorticoid therapy may be needed.


  • CAFR is controlled via restrictive diet.

  • Treatment options for atopic dermatitis include but are not limited to:

    • Immunotherapy

    • Cyclosporine A

    • Antihistamines

    • Fatty acids

    • Adjunct topical antiinflammatory and/or antimicrobial therapy


  • Requirements depend on cause.

  • For infections, recheck clinical and cytologic response in 2–3 weeks to ensure topical and/or oral therapy is effective.

In General

Relative Cost

  • Cost can vary.

  • Lip fold intertrigo (diagnosis and treatment): $–$$

  • Cheiloplasty for lip fold intertrigo: $$$$

  • Zinc-responsive dermatosis (diagnosis and management): $$–$$$

  • Generalized demodicosis management: $$–$$$$

  • Immune-mediated disease (diagnosis and management): $$$–$$$$$

  • Superficial necrolytic dermatitis (diagnosis and management): $$$$–$$$$$

*A complete discussion of therapy is beyond the scope of this text.