This episode is bought to you by Quell — to help support rebuilding healthy skin from the outside-in + inside-out!
Take 10% off your next order! Use promo code QUELL10 at check out — Get started HERE!
– – –
If you have perioral dermatitis or wonder what is perioral dermatitis — you're in for a treat because we're diving into root causes + alternative perioral dermatitis treatment options you probably haven't heard of!
I say this because one specific perioral dermatitis treatment can actually make your rash SO MUCH WORSE.
Though I have one other episode on perioral dermatitis (mostly focused on environmental exposures that can trigger it), this episode is a fantastic deep dive into what can make perioral dermatitis better + worse both from the inside-out AND outside-in.
Today's guest is Dr. Julie Greenberg, a licensed Naturopathic Doctor (ND) and Registered Herbalist RH(AHG) who specializes in integrative dermatology. She is the founder of The Center for Integrative & Naturopathic Dermatology Inc, a holistic clinic that approaches skin and hair problems by finding and treating the root cause. She is also the founder of RootCauseDermatology.com, a medical education website that trains functional medicine practitioners on how to treat dermatological conditions using her cutting-edge approach. Dr. Greenberg holds degrees from Northwestern University (BA), Stanford University (MBA) and Bastyr University (ND). Her research on the gut microbiome of acne patients has been published and presented at multiple conferences. She teaches dermatology classes at naturopathic medical schools and is a highly sought-after speaker at conferences across the U.S.
If you've ever had perioral dermatitis, how long did it take to get a diagnosis and did you find relief? Tell me what worked for you or what didn't in the comments below!
Or, listen on your favorite app: iTunes (Apple Podcasts) | Spotify | Stitcher | TuneIn | Subscribe on Android
In this episode:
- What is perioral dermatitis + what conditions is it often confused with?
- Perioral dermatitis causes (including some really surprising ones (like a common medication))
- What your alternative perioral dermatitis treatment options include
- Connection of yeast, parasites + demodex mites to perioral dermatitis
- What if you have perioral dermatitis around your mouth? (special considerations)
- Perioral dermatitis in kids – discussion of an 8-year-old client case
Quotes
“Malassezia is a fungal organism. It's a yeast, which is a single-celled fungal organism. It's on everybody, but sometimes it can cause skin disease. And in the acne section, we talked about acne can be both bacterial acne, that kind of classic cutibacterium acne, but it can also be fungal acne, which is like a Malassezia folliculitis.” [07:42]
“I have recommendations for toothpaste, mouthwash, tongue scraper, and dental flosses, because whatever's in the mouth, that oral microbiome, it is going to come out and affect around the mouth.” [25:02]
Links
Find Dr. Greenberg online | Instagram | take her courses
Healthy Skin Show 173: Malassezia: The Bug Behind Many Fungal Skin Problems w/ Dr. Julie Greenberg
Healthy Skin Show 149: How Staph Aureus Wrecks Your Skin w/ Dr. Julie Greenberg
Healthy Skin Show 220: The Gut Microbiome Of Acne [NEW RESEARCH] w/ Dr. Julie Greenberg
Try Risewell for some great toothpaste and oral care products (no fluoride). Use HEALTHYSKINSHOW for 10% OFF!
310: Integrative Perioral Dermatitis Treatment Options w/ Dr. Julie Greenberg, ND {FULL TRANSCRIPT}
Jennifer Fugo (00:08.13)
I'm so excited that you're back here on the podcast, Dr. Greenberg. Thank you for being here with us.
Dr. Julie Greenberg, ND (00:13.474)
Thanks so much for having me, Jennifer. You know I'm a huge fan of the podcast.
Jennifer Fugo (00:17.602)
Well, you're also one of the favorite guests. And today, we're going to talk about a topic that I've only had one other guest talk about, and it is perioral dermatitis, which I find that people who have perioral dermatitis are extremely frustrated. It's sort of unclear, at least when they go to their doctor, what might have triggered it. We're going to talk all about that. You've actually got some great information on that; and understanding also how it's different from other skin conditions. So I'm really excited to have this conversation with you because it is, I would also say, or like other skin conditions, it's embarrassing because it is a lot of times on your, it's your face. And so you're either having to wear makeup to cover it up. So let's dive into that. What exactly is perioral dermatitis?
Dr. Julie Greenberg, ND (01:11.39)
Yeah, out of everything you said, I think that the word unclear was like the key word for me. So there's so many reasons why it's unclear. The definition of perioral dermatitis is actually, I'll give you the technical and then I'll explain it in lay terms, but erythematous papules around the mouth, eyes, and nose. So erythematous papule, erythema means redness, and a papule is kind of like a bump.
So it's basically like red bumps around the mouth, eyes, and nose. I've just described so many skin diseases. And sometimes it's called periorificial dermatitis. So that's the term for the whole face because it can be in the periocular region, so around the eyes and also perinasal around the nose as well as the perioral around the mouth. So yeah, I mean the official definition is just red bumps around the mouth, eyes and nose. And that means that it can kind of be many different types of skin diseases.
Jennifer Fugo (02:16.246)
So with this type of condition, would it warrant diagnosis through like a biopsy or is it usually just the dermatologist looks at your face and is like, oh, you have red bumps. This is what it is.
Dr. Julie Greenberg, ND (02:30.058)
Yeah. So, I mean, technically you could do a biopsy. I think it's like really rarely ever done. And the biopsy, there's nothing like super special in the biopsy. Like there are diseases where we can definitely very clearly diagnose, but it's kind of like a lymphocytic infiltrate. So it's also like a little nonspecific. And that's, I think, what also makes PD or PO, perioral- periorificial dermatitis, you know, so frustrating, is that it can be hard to differentiate, like is this rosacea, is this acne, is this seborrheic dermatitis, is it a contact dermatitis, is it eczema, or is it those base things plus like a perioral derm? I think a perioral dermatitis is kind of like one of those catch-all buckets for these bumps that occur in these areas that's not something else. So it's kind of like an IBS, right? An irritable bowel syndrome. You really only get a diagnosis of irritable bowel syndrome when everything else is ruled out and they can't give you a specific GI or gastrointestinal disease. Like, okay, it's not Crohn's, it's not ulcerative colitis, you know, it's not this, that, the other. They just call it IBS. Sometimes that happens with bumps kind of in this area that they don't think is rosacea, they don't think it's acne or any of the things I just mentioned, then they'll just call that perioral dermatitis. But yeah, it's a little amorphous, the diagnosis and if you look in the literature, like the actual diagnosis, the frequency, 0.5% to 1% of the population, which to me feels a little bit low, but I think it could be happening with other things as well and or be misdiagnosed as something else.
Jennifer Fugo (04:27.558)
So one interesting thing that I have read about and I've actually heard about from folks online who have had peri, well at least the perioral dermatitis form was that it can be triggered by steroid use. So topical steroids, I would assume when they say that. Can you talk a little bit about that?
Dr. Julie Greenberg, ND (04:52.246)
Yeah, it's one of those kind of weird things and that at the beginning, when people first start using steroids, it can quench the perioral dermatitis or whatever like issues happening on the face that's causing them to use the steroids, but absolutely chronic use of topical steroids is one of the causes of perioral dermatitis. So chronic use, it can also happen with with nasal steroids. So people who are using stuff like Flonase, you know, for allergies and inhaled corticosteroids. So it doesn't even have to just be the topical stuff. The nasal and inhaled can get onto this area. And when people are using this chronically for like other diseases, it can actually be the cause of perioral dermatitis.
Jennifer Fugo (05:44.826)
Wow, and so does that make it more tricky to treat, or do you think that it's still worthwhile? Because I know we're going to dive into some things under the surface. Does it still make it worthwhile to look under the hood if it was triggered by some sort of steroid exposure?
Dr. Julie Greenberg, ND (06:04.438)
Yeah, I mean, obviously if someone has been using steroids for a long time, either topical, inhaled or nasally, and you think you have this condition around the mouth, nose, you know, or maybe even the eyes, the first thing you would do if you can is to try to stop using the steroid and see if it will go away. But there's also like a long list of other causes of perioral dermatitis. So if you take away the steroid and that doesn't clear it, then you kind of need to run down these other list of issues and see if that could be driving it.
Jennifer Fugo (06:40.934)
So let's talk about that. What would be some of the other things, and maybe we could start with the things that are more known, maybe your dermatologist has told you if you've been diagnosed with this, versus some other things that you might not have even heard of or been told about yet.
Dr. Julie Greenberg, ND (06:59.306)
Yeah, so I think the more common ones that maybe your dermatologist or your doctor would be talking to you about would be what else are you putting on your skin? What kind of moisturizers or makeup, like foundations or sunscreens that could be causing some sort of maybe a contact dermatitis or irritation on the skin? So hopefully, you know, running through that and make sure there's nothing in there.
And then infectious agents. So we know that there can be kind of like a bacterial or fungal infection, either candida or Malassezia yeast. And I've talked about Malassezia before, so you can link, I won't go too far into that. You can link to that. But Malassezia is a fungal organism. It's a yeast, which is a single-celled fungal organism. It's on everybody, but sometimes it can cause skin disease. And in the acne section, we talked about acne can be both bacterial acne, that kind of classic cutie bacterium acne, but it can also be fungal acne, which is like a Malassezia folliculitis. So those things can certainly be involved in perioral dermatitis, but also something that people may not realize is living on their skin that's different. It's a little mite called Demodex mites, and they're on just about everybody. So we are colonized. If you've ever seen a picture, they look like the scariest alien. They're just so gross. I mean, they're infinitesimal. Like multiple of them can fit on a pinhead. But the Demodex mites live in our eyelashes, down in the hair follicle, as well as like on the face in the hair follicles. Even here, we've all got little hairs, little vellus hairs, and they live down in the follicle and eat the sebum, which is the oil produced by the sebaceous gland. So demodex mites could be a factor in perioral dermatitis as well as other diseases like rosacea. And then inside the demodex mites, so we're not the only ones who are colonized by bacteria and fungus. The teeny tiny mites even are colonized by bacteria and inside of them is a bacteria called bacillus oloronius and when they die and their kind of guts and stuff spill out into our hair follicle, this Bacillus Oloronius is released and there's a whole thing on rosacea about Demodex and the Bacillus bacteria, but there seems to also be perhaps a relationship with perioral dermatitis and we can get into treatment for them.
But again, it's like these big questions because we've all pretty much got Demodex. So what's going on that might be triggering the perioral germ, you know, there's a lot of questions. But those I think are the kind of well-known, like, you know, topicals, makeup, steroids, infectious agents, and then maybe the less known are fluoridated toothpastes. There's studies that show that might be related, as well as even like chewing gum or dental fillings. So, you know, we have to remember that whatever we're putting in our mouth, like it can kind of come out and when we get into kind of treatment recommendations, I'll tell you how I approach the oral and the nasal microbiome. And even hormonal factors in females, sometimes birth control can actually help. So that's kind of more a little bit of like that acne type picture. Yeah. So the weird thing about perioral dermatitis is it really does kind of touch on different diseases. Like there's aspects of acne. There's aspects of rosacea. Aspects of seborrheic dermatitis and it's just this kind of weird disease.
Jennifer Fugo (10:47.942)
Yeah, I had a client once who was treated with minocycline. And when she asked why she was being given an antibiotic, she was curious if there was sort of like gut reason. And they're like, oh, no, no, no. It's just anti-inflammatory. That's it.
Dr. Julie Greenberg, ND (11:06.698)
Yeah, so that's the same answer for acne and rosacea. It's a low dose, it's a low dose oral antibiotic, and usually it's like doxycycline or minocycline or serocycline, it's the tetracycline group. And it's not the same dose you'd be given, let's say you had a staph infection on your skin, that's a really different dose of let's say doxycycline than if you have acne, rosacea or perioral dermatitis, then you're on a longer term low dose often for like three or four months. And yet it's like they think it's not a high enough dose to actually be antibacterial, but there are these kind of general anti-inflammatory effects that you can get from it. And so that is why they're on a low dose for a long period of time. But even they can't really explain like what that means and why it's working.
Jennifer Fugo (12:01.594)
Yeah, well, I actually do think that there could be some underlying gut microbiome pieces to this. I don't know, I imagine you might feel the same. I also had experience working with, oddly enough, an eight-year-old who was the daughter of a client who developed perioral dermatitis, and she actually had a parasite. And that was what was triggering it. And I've seen that actually in two different cases, one an adult and obviously one in an eight year old. So thoughts on just in general, the gut microbiome, does it play a role in this?
Dr. Julie Greenberg, ND (12:37.962)
Yeah, I think it does. A lot of how I treat perioral dermatitis is basically how I'm treating acne. And we've talked about that, but I'll just kind of recap. Yeah, so I do gut microbiome testing on all my patients. So they have to do a stool test and a urine test called an OAT-organic acids test. And the reason is exactly like you're saying, I wanna see what's happening in their gut. The stool test does an excellent job with looking at the bacteria that are there or maybe are missing from their gut. Also digestive function and parasites, things like protozoa. And then I feel like the organic acid tester, OAT, does a much better job with the fungal piece. And then I can really kind of, with those two tests, see what's going on and treat. My acne patient, I mean, I have hundreds and hundreds and hundreds of them. I don't have that kind of database for perioral derm, because as we talked about, it's like half a percent to 1% of the population. And I think a lot of times there's overlap with the other diseases we talked about, but at least in acne, almost all of my acne patients have H. pylori, which is a bacteria that lives in the stomach. Almost all have Candida overgrowth and half have a parasite, particularly a protozoa. There's lots of different types of protozoa. There's pathogenic protozoa like Giardia, but there's other protozoa like blastocystis hominis, endolymaxnana, dientamoeba fragilis, and others that in this kind of functional medicine world, some people say like, oh no, they're good little parasites, just leave them alone. But I, and they say that about H. pylori, but I find every time I really need to clean up the H. pylori and the parasites, and then the skin gets better. I don't know if you remember, but I'd be interested to know what parasites you found in that eight year old.
Jennifer Fugo (14:30.306)
So both the eight-year-old and the adult female both had blastocystis hominis.
Dr. Julie Greenberg, ND (14:36.034)
Right, and so it's the same thing. Some functional medicine doctors and naturopathic doctors will say, oh no, let's just leave it alone. It's not doing anything. But I think for those of us who specialize in skin, we see it is doing something and you really need to get rid of it. And yeah, it's not abnormal. The two kind of groups that tend to suffer from period oral dermatitis the most are children and then kind of young female adults, so.
Jennifer Fugo (15:04.927)
So with the gut microbiome, and obviously, I guess that's partly to, although it's in low antibiotic dose, it likely is having some sort of impact. I mean, it could have an anti-inflammatory impact, but let's be honest. We know that things like processed foods and stress can impact the gut microbiome. So why you would assume that low dose antibiotics likely doesn't do anything seems slightly implausible. So I think we don't fully probably understand exactly what the impact is. But in terms of the gut issue, obviously working through gut protocols and whatnot, but then there's also the topical piece, because again, my experience has been, at least with the adult female that I worked with, actually I've had two adult females that I've worked with. Okay, three cases off the top of my head that I've worked with, but it's embarrassing. It's really, really embarrassing.
Dr. Julie Greenberg, ND (16:01.13)
It is. Any time we have a skin disease on the face, the severity rating by the patient, the impact on their life shoots way, way up. Some of my patients with facial issue, you know, dermatitis issues were actually relieved during COVID that they had an excuse to wear a mask over their face and kind of try to cover it up as long as it wasn't on the forehead. If it was in here, they were almost relieved, like, ah, I have a reason to cover this up. Yeah, so it's really impactful to patients, adult patients with perioral derm or acne. I think they feel embarrassed like, ugh, like, why do I have this? Like, I'm not a teenager going through puberty, you know? I shouldn't have like, red bumps and crazy stuff going on in my face. And, yeah, it's, I think people who don't have it can't appreciate the real emotional and psychological impact on people.
And even kids because kids wanna know what's wrong and isn't contagious and all this stuff. And it's really important to be able to help these patients and clean it up just because I know even from a professional perspective, I mean, people feel like they can't like go into a business meeting and be taken seriously when they've got like all this stuff going on. And you can't always just cover it up with foundation and that can even make it worse.
Jennifer Fugo (17:25.122)
Yeah. And just to be clear, perioral dermatitis is not contagious, correct?
Dr. Julie Greenberg, ND (17:34.578)
Not that we know of. I mean, again, it's, you know, it kind of, there's this handful of reasons, but it doesn't seem to be a contagious element. It's not like a herpes virus or something like that, where, you know, those you can, or like a molluscum. It's not something like that where we believe that it's like transmittable.
Jennifer Fugo (17:54.498)
Okay, and so in terms of topical perioral dermatitis treatment options, because this is definitely an inside out, outside in scenario, what are some topical things that you have found helpful with your patients?
Dr. Julie Greenberg, ND (18:08.49)
Yeah, so exactly as you said, there's the inside out. So I go in and I test the gut. I'm gonna treat all those issues we talked about, whatever's overgrowing in the system or the gut that needs rebalancing. And then from a topical perspective, it kind of depends on what I think is going on. If I think there's a Demodex component, those mites, and it's kind of got that like rosacea picture, and sometimes when it's around the eyes, I'm more suspicious of the Demodex because the Demodex mites live in the eyelashes. There's two different types. There's Demodex follic, follic, follic, I'm gonna mispronounce it. Demodex F and Demodex B for Brevis. And the F lives in the eyes and the B for Brevis lives in the sebaceous glands. But if it's like all three, you know, it's probably not like just like a steroid or something like that. And so with Demodex mites, there's actually a pharmaceutical called ivermectin that can be really helpful. There is a topical form of it, it's called Soolantra. That is a prescription only, so that's not something that patients can just go out and buy themselves. They need a prescription for it. And it has to be used for a prolonged period of time, like often, like several months, like up to three months. And it's one of those things where things can get worse before they get better. We're not sure exactly why, but it may be that, I mean, we know that the Soolantra kills off the demodex and it may be that as the demodex mites die and kind of release their innards, whether it's that Bacillus oleronius bacteria or whatever is just contained within the mite body, it could be kind of exacerbating the skin. And so you kind of got to work through all of it for a few months and then things are cleared up afterwards.
There is an oral ivermectin, which is usually given in one or two doses separated by a week or two. The theory being we're gonna kill the adult mites, but they could have laid eggs. So we're gonna do a second dose like one to two weeks later and get those hatching baby mites. The problem with oral ivermectin is, ivermectin may sound familiar to some of your listeners because in COVID, there was this big drive by a kind of subsection of people stating that ivermectin could prevent COVID or treat COVID even though there's not really literature to support that. And so it became a big deal in the conventional community and doctors who were prescribing ivermectin for COVID were getting their licenses pulled. And oral ivermectin, so it's oral ivermectin is an anti-parasitic drug. So it is definitely prescribed for certain situations, but it's considered off label for things like rosacea and perioral dermatitis. So I have not found a doctor who's willing to prescribe oral ivermectin for any of my rosacea or perioral dermatitis patients since COVID began, but they are usually willing to prescribe the topical ivermectin, Soolantra. It's a lot more expensive, it takes more time, and you have that thing where things can get worse instead of better, but I think it's a reasonable option if you're suspicious that the Demodex mite is involved.
As far as other topicals for perioral dermatitis treatment, what I'm usually using is the kind of stuff that I'm using in my acne patients. So I'm using natural botanicals. I usually don't use pharmaceuticals in like 99% of my plans, but Demodex is its own thing. There's not really great topicals to go get Demadex, so that's why the pharmaceuticals are easier, but for acne, I'm using gentle botanicals that support the skin, so nothing like harsh cleansers, using things like carrier oils with essential oils in it, but when I know we've had this conversation, I do not recommend that people go out and start like putting essential oils or doing their own blends. Never, never put essential oils straight on your skin, which is called neat. That's a great way to develop contact allergic dermatitis and an allergen to that essential oil. But I do find that existing blends or if you have a knowledgeable provider, that carrier oils that are good for acne. So we're talking about things like jojoba oil, grape seed oil- not coconut oil that's going to clog the pores- and then certain essential oil blends can be really helpful. And a lot of times if there's that kind of bacterial or fungal component to it, that's enough to clean things up along with the gut work.
Jennifer Fugo (23:02.31)
And I will share as well, and this is sort of going back to the eight-year-old that I worked with. Ironic, her mother was like, I don't know if you can help, but I'll also add to this, she had a lot of trouble sleeping at night. She was always waking up in the middle of the night. She was coming into their bed, the parents' bed, waking them up. She was having nightmares. And then because she was tired, she was having trouble at school, focusing, concentrating, and whatnot. And her mother shared that after… And actually the pediatrician is who ultimately treated her for the blasto because her calprotectin was like through the roof. So she was treated with medication. But her behavior completely changed after being treated and her face did clear up. So I do think it's worthwhile to consider. I mean, obviously, the blasto wasn't quite the whole picture, but it was a big factor. So I do think it's worthwhile to consider that there could be something going on under the surface. And again, I don't have enough experience with that many cases, but it was fascinating to watch this process for these handful of clients whom I've worked with.
Dr. Julie Greenberg, ND (24:19.05)
Yeah, 100% I agree. And then the last thing that I didn't mention but I alluded to at the beginning is if I have patients with issues around the mouth, I'm gonna also take a look at the oral microbiome. And if I have patients with issues around the nose or between the nose and mouth, I'm gonna take a look at the nasal microbiome. So I will treat depending on where the perioral dermatitis is.
If it's just around the mouth, but not coming up under the nose, I'm gonna ask them, you know, not just whether they use fluoridated toothpaste, but what is their hygiene protocol? What toothpaste are they using? Are they flossing their teeth? Is it daily? Do their gums bleed? Do they have issues in their mouth? And I have recommendations for toothpaste, mouthwash, tongue scraper, and dental flosses, because whatever's in the mouth, that oral microbiome, it is gonna come out and affect around the mouth.
And then if it's in this area where it's around the nose or between the nose and the upper lip, then I'm also gonna suspect the nasal microbiome. And there's all sorts of things that can be living up there, fungal, bacterial. There are labs where you can go up and do a swab. At first I was doing swabs to see what was up there and there's some interesting stuff. But then I realized, you know, my treatment was pretty much gonna be the same. So we do that less and less because it can be a couple hundred dollars.
And I just use also natural botanical nasal sprays, things with colloidal silver. There, even like the Flonase situation, you know, patients might be like, oh, what am I gonna use if I'm not using Flonase? There are things with like colloidal silver, but like mast cell inhibitors, and there can be things like quercetin in the spray, echinacea and other things. So a lot of my patients, not even perioral derm, we can get them off the Flonase just by cleaning up the passages and using botanicals up there. But for other microbes in the nose, propolis nasal spray can work. There's xylitol nasal sprays with essential oils. There's ways to make essential oil blends, but again, know what you're doing before you do that. So really cleaning up this oral and nasal microbiome can help, and we talked about Malassezia.
Malassezia can cause issues on the eyes as well. So just gentle washes of the eye or even like tea bag treatments on top of the eye. Sometimes that can help with the perioral derm if it's periocular.
Jennifer Fugo (26:55.39)
This has been so fascinating. I'm so glad that I asked you about this because I've been wanting to dive into this deeper and I know that people have asked. So I'm sure that anyone listening to this is like, oh my gosh, there is so many more options that I was imagining could be. And I think that for many listeners, they love to know that there are actually other things they can do than just take antibiotics.
So I'm really excited to share this with everyone. And obviously you are in practice, so you're seeing patients and you also train professionals as well. And so how can everybody reach you?
Dr. Julie Greenberg, ND (27:36.534)
Yes, so if any of your listeners live in California, Oregon, or Washington, that is where I'm licensed as a naturopathic doctor and where I see patients. So they can head to integrativedermatologycenter.com and check out how to schedule an appointment with me there. If any of the folks are listening and are not in those three states or maybe you're professional and you're interested in treating derm patients from a more functional medicine approach. As you said, I have a course and a training site that's at rootcausedermatology.com. I have courses there for folks who live outside my state so they can take them. And I have a training, a functional medicine training course for professionals. It's a four month intensive and it runs in cycles. And so people can see all those courses at rootcausedermatology.com.
And if you have listeners who aren't in my three states, there's a find a practitioner link and they can find a practitioner who's been through my course and is certified in my methods and Hopefully one way or another I'll be able to help
Jennifer Fugo (28:43.61)
Perfect. Well, thank you so much for coming back. I really appreciate your time. And we'll put all of the links to the episodes that you mentioned that you've already done here on the Healthy Skin Show in the show notes, as well as how to get in touch with you. And thank you so much, Dr. Greenberg, for being on the show.
Dr. Julie Greenberg, ND (28:59.09)
Awesome, thanks so much for having me.
