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Canine Perioral Dermatitis

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

Dermatology

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August 2013
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Peer Reviewed

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Canine Perioral Dermatitis

Profile

Definition

  • 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.

Related Article: Perioral Dermatitis in Dogs

Systems

Clinician's Brief
  • 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.  

Figure 1. Lip fold intertrigo in a dog

Signalment & Causes

Clinician's Brief
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).

Figure 2. Discoid lupus erythematosus in a dog

Pathophysiology

  • 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.

Related Article: Chin Dermatitis in a Cat

History

  • 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.

Clinician's Brief
Diagnosis

Definitive Diagnosis

  • Definitive diagnosis is achieved via history, examination, and appropriate diagnostics (see Perioral Dermatitis in Dogs, a Management Tree).
  • Secondary infections should be resolved, as they can confound clinical and histopathologic features of the primary cause.
  • Clinician's Brief
  • Histopathology is required for diagnosis of immune-mediated disease, superficial necrolytic dermatitis, zinc-responsive dermatitis (Figure 3. Zinc-responsive dermatitis in a dog), and cutaneous epitheliotropic lymphoma (Figure 4).
  • Clinician's Brief
    Figures 4a, 4b, & 4c. Cutaneous epitheliotropic lymphoma in various canine patients
  • Patients with nonseasonal perioral pruritus may require an 8-week prescription or home-cooked elimination diet to differentiate atopic dermatitis (Figure 5. Atopic lip fold dermatitis with cheilitis and secondary Staphylococcus spp infection) from cutaneous adverse food reaction (CAFR).
  • Cytology

    • 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.

    Clinician's Brief
    Deep Skin Scrape

    • Deep skin scrape or pluck for Demodex spp (Figure 6. Perioral and facial demodicosis in a dog) 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

    Cultures

    • Dermatophyte culture is indicated if lesions are consistent (see Table 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.

    Clinician's Brief
    Histopathology

    • Vesiculobullous presentations (Figure 7. Mucous membrane pemphigoid in a dog) and lesions that remain after resolution of secondary infection should undergo biopsy.
      • Multiple lesions representing all stages of disease should be sampled.

    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. 

    CAFR = cutaneous adverse food reaction

    Treatment

    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

    Dermatophytosis

    • These infections should be treated systemically and topically (see Malassezia spp Infection).
      • Lime sulfur may be used for generalized presentations.

    Immune-Mediated Conditions*

    Clinician's Brief

    • 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.

    Figure 8. Juvenile cellulitis in a dog

    Vitiligo

    • 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 (Mitaban) dips q14d
      • Ivermectin (Ivomec) at 0.3–0.6 mg/kg PO q24h
      • Milbemycin oxime at 1–2 mg/kg PO q24h
      • Doramectin (Dectomax) at 0.6 mg/kg PO or SC q7d2
      • Topical 10% imidacloprid and 2.5% moxidectin (Advantage Multi for Dogs) 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 (Aminosyn) 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. 

    Hypersensitivity

    • 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

    Follow-up

    • 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): $–$$
    • Cheiloplasty for lip fold intertrigo: $$$$
    • Zinc-responsive dermatosis (diagnosis and management): $$–$$$
    • Generalized demodicosis management: $$–$$$$
    • Immune-mediated disease (diagnosis and management): $$$–$$$$$
    • Superficial necrolytic dermatitis (diagnosis and management): $$$$–$$$$$
    Cost Key
    $ = up to $100    
    $$ = $101–$250    
    $$$ = $251–$500
    $$$$ = $501–$1000
    $$$$$ = more than $1000

    CAFR = cutaneous adverse food reaction

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

    References and Author Information

    For global readers, a calculator to convert laboratory values, dosages, and other measurements to SI units can be found here.

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