Your allergy meds may be causing this surprising skin symptom
In the midst of yet another long and grueling allergy season, some people might be noticing an unexpected complication: bumps on around their nose and mouth. This itchy, stinging rash is a skin condition known as perioral dermatitis — and it can be related to the use of steroid nasal spray allergy medications.
These medications (like Flonase, Nasocort and Rhinocort) work by reducing inflammation, Dr. Jonathan A. Bernstein, president of the American Academy of Allergy, Asthma and Immunology, tells TODAY.com.
They primarily do this by inhibiting the production of cytokines, he says, which are proteins involved in creating the immune responses that lead to allergy symptoms, like congestion.
But, in some cases, steroid medications can also affect the surrounding skin on your nose, possibly causing a flare of perioral dermatitis, Dr. Teo Soleymani, a board-certified dermatologist based in Pasadena, California, tells TODAY.com. Rarely, the medication causes a person to develop perioral dermatitis for the first time, but usually, people who experience the condition when using steroids already have it, even if it's mild, and the spray causes a flare-up.
Soleymani often sees an increase in patients coming in with perioral dermatitis around the spring and fall when they typically start using these medications. "When allergies are worse and patients' asthma is worse, we do see an increase in perioral dermatitis related to inhaled steroids as well, especially nasal sprays," he says.
What is perioral dermatitis?
Perioral dermatitis is a very common — and often misdiagnosed — skin condition, Soleymani says.
The condition usually appears as a rash of small red or flesh-colored bumps around the nose and mouth, he says. The rash might also be itchy, burning or sensitive, the American Academy of Dermatology explains, and it can cause dry, flaky skin in the area.
"It's often mistaken for some sort of eczema-like rash or contact dermatitis, but it actually falls in the acne and rosacea family," Soleymani explains. Although it doesn't look like acne or rosacea, under a microscope, the way perioral dermatitis behaves is very similar to those other conditions, he says.
In particular, people who have rosacea are also more likely to develop perioral dermatitis, Soleymani says. "Some people believe (perioral dermatitis and rosacea) overlap, and some people think that they're literally on one continuum."
Steroid use can cause a perioral dermatitis flare
The link between the use of steroid medications and perioral dermatitis "is a common and well-known one — especially to dermatologists," Soleymani confirms.
Dermatologists often see patients develop symptoms of perioral dermatitis, and thinking it's a different type of rash, they try to treat it at home with over-the-counter, topical steroid creams.
These creams are "notorious for temporarily masking and suppressing perioral dermatitis, only to have it re-flare shortly after stopping the topical steroid," Soleymani says. At that point, patients typically realize that, as soon as they stop using the creams, their symptoms return, and they seek further help from their doctor or dermatologist.
Treating perioral dermatitis often requires a course of oral antibiotics, as well as avoiding triggers and sticking to a sensitive skin-friendly routine, the AAD says.
Experts don’t fully understand the link between these medications and perioral dermatitis, but it’s thought to be an inflammatory response related to a dysfunction in the immune system. Using a steroid medication temporarily dampens that inflammatory response, but not the underlying issue with the immune system, Soleymani says. So when people stop taking the medication, their symptoms return.
"The idea is that (the medication is) affecting some of the normal immunomodulatory responses," Bernstein says. "So it could be allowing changes in the microbiome that could make people more susceptible to infection."
But, generally, if people are using the medications properly, that shouldn't be happening frequently, he says.
Perioral dermatitis and nasal allergy steroid sprays
While perioral dermatitis flares happen most frequently with topical and oral steroid medications, "we also see this in steroids that are a spray, such as Flonase," Soleymani says.
That's partly because the area of the nose that gets sprayed — the opening around the nostril — also tends to flare with perioral dermatitis. The other issue is that, if some of the medication drips down out of the nostril, it can get absorbed in the skin, which can also lead to a perioral dermatitis flare down the line.
Part of that can be due to not spraying the medication deep enough in the nostril, Bernstein says. "They are often using it incorrectly; if it's perioral, they're not getting it into the nose," he adds.
Sometimes people notice the link between nasal steroid sprays and perioral dermatitis after a few weeks of using it, or if they use it and take a break, Soleymani says. "They say their perioral dermatitis looks OK or a little bit better initially and then it comes right back," he explains. Or they might notice that, after a few weeks of using those medications, their rash starts to look worse.
"That's the same, age-old phenomenon that topical steroids don't treat perioral dermatitis. They just mask it temporarily," Soleymani says.
It’s important to note there are also rare instances of steroid-induced perioral dermatitis, rosacea and acne, Soleymani says. In those cases, the rash or condition appears uniformly when patients start using these medications.
But this is far less common than a scenario in which someone has perioral dermatitis first — maybe a very mild version they don’t even notice — and then develops a flare after using the steroid medication, Soleymani says.
What to do if you have allergies and sensitive skin
If you're prone to perioral dermatitis or other sensitive skin issues, you don't have to stop using your nasal allergy steroid sprays. But it's worth talking to your doctor, allergist or dermatologist before using them — and keeping an eye out for any skin side effects, the experts say.
Even though the medications are available over-the-counter, "they should be used under the supervision of a physician," Bernstein says. If you're using a nasal allergy steroid spray for the first time, get guidance from your doctor, allergist or immunologist, he says, adding that he frequently has these conversations with his own patients.
Be sure that you're using the medication correctly and according to the directions on the package. In particular:
Make sure you're spraying the medication at the right angle to get it deep enough into your nostrils.
Don't let the medication drip onto your skin by tilting your head. If it does drip out, blot it quickly with a paper towel, Soleymani says.
Don't skip days. Using the medication inconsistently can trigger a flare.
But it's also important to keep in mind that if you're experiencing perioral dermatitis, steroid sprays are not the only potential trigger, and the cause may not be what you think it is, Bernstein says. It could also be related to a skin- or body-care product or something in your work environment, he says.
So, if you notice symptoms that look like perioral dermatitis, it's definitely worth getting them checked out by your doctor or a specialist.
In the event that you and your doctor confirm that your nasal spray is triggering perioral dermatitis symptoms, "the first thing you should look at is what bothers you more," Soleymani says.
Perioral dermatitis, while a painful nuisance, isn't dangerous. But allergy-related symptoms, especially asthma symptoms, can impact your life and ability to breathe. If you're using the nasal steroid spray to combat those symptoms, you may decide it's worth putting up with some perioral dermatitis bumps.
"You have to find that balance of what's the lesser of the evils," Soleymani says. But that's not something you should do on your own or by just consulting Dr. Google, Bernstein says.
These medications are used frequently to safely manage allergy symptoms and are "important therapies," he says. So you don't want to rule out a helpful tool without talking to an expert first. "Our job as clinicians as physicians is to help guide the patient properly and to be their advocate," Bernstein adds.
This article was originally published on TODAY.com
