What are the treatment options for seborrheic dermatitis?

Treatment Options for Seborrheic Dermatitis

Topical antifungal medications are the mainstay of therapy for seborrheic dermatitis, with ketoconazole being the first-line treatment due to its effectiveness in reducing Malassezia yeast colonization and controlling inflammation.

Pathophysiology and Clinical Presentation

Seborrheic dermatitis is a common chronic inflammatory skin disorder affecting areas rich in sebaceous glands, particularly the scalp, face (especially nasolabial folds, eyebrows, and eyelids), ears, chest, and other sebum-rich areas. The condition is characterized by:

• Greasy yellowish scaling
• Erythema (redness)
• Pruritus (itching)
• Secondary inflammation

The pathogenesis involves:

• Malassezia yeast colonization
• Sebaceous gland hyperactivity
• Inflammatory immune response
• Possible genetic predisposition

Treatment Algorithm

First-Line Treatments

1. Topical Antifungals:

   • Ketoconazole (1-2% cream, shampoo): Apply to affected areas twice daily for face/body; use shampoo 2-3 times weekly for scalp 1, 2
   • Ciclopirox (1% cream, shampoo): Alternative antifungal option with similar efficacy 1
   • Zinc pyrithione (1-2% shampoo): Particularly effective for scalp seborrheic dermatitis 3

2. Topical Anti-inflammatories (for short-term use only):

   • Mild-to-moderate potency corticosteroids: Use for 1-2 weeks to control inflammation 1, 2
   • Topical calcineurin inhibitors (tacrolimus, pimecrolimus): Off-label use for facial seborrheic dermatitis, especially when corticosteroids are contraindicated 1

3. Keratolytic/Humectant Agents:

   • Coal tar (0.5-2% shampoo): Effective for scalp involvement 4
   • Propylene glycol: Helps with scale removal 1

For Scalp Seborrheic Dermatitis

1. Start with medicated shampoo containing one of the following:

   • Zinc pyrithione 1-2%
   • Ketoconazole 1-2%
   • Coal tar 0.5-2%
   • Selenium sulfide 1-2.5%

2. Apply shampoo to affected areas, leave on for 5-10 minutes before rinsing

3. Use 2-3 times weekly initially, then reduce to once weekly for maintenance

For Facial and Body Seborrheic Dermatitis

1. Gentle cleansing with non-soap cleansers
2. Apply topical antifungal cream (ketoconazole or ciclopirox) twice daily
3. For flares with significant inflammation, add short-term (7-10 days) low-potency topical corticosteroid
4. For steroid-sensitive areas (face), consider topical calcineurin inhibitors

Second-Line Treatments

For resistant or severe cases:

1. Systemic Antifungals:

   • Itraconazole
   • Terbinafine
   • Consider for widespread or resistant disease 1, 5

2. Phototherapy:

   • UVB phototherapy for resistant cases 1

Special Considerations

For Infants ("Cradle Cap")

• Gentle baby shampoos with emollient agents
• Medical device shampoos containing piroctone olamine, bisabolol
• Vegetable oils to soften scales before gentle removal 1

Maintenance Therapy

After initial control is achieved, maintenance therapy is often necessary:

• Weekly medicated shampoo for scalp
• Twice weekly application of topical antifungals for face/body

Common Pitfalls and Caveats

1. Avoid prolonged use of topical corticosteroids, especially on the face, to prevent skin atrophy, telangiectasia, and tachyphylaxis 2

2. Beware of allergic contact dermatitis to topical medications, particularly neomycin which can cause sensitization in 5-15% of patients 6

3. Differentiate from similar conditions:

   • Psoriasis (less pruritus, more defined plaques)
   • Atopic dermatitis (different distribution, personal/family history of atopy)
   • Contact dermatitis (history of exposure to allergens/irritants)
   • Tinea (positive fungal culture, peripheral scaling) 6

4. Consider underlying conditions that may exacerbate seborrheic dermatitis:

   • HIV infection
   • Parkinson's disease
   • Immunosuppression 6

5. Avoid greasy topical products in seborrheic areas as they can promote superinfection 6

By following this treatment algorithm and avoiding common pitfalls, most cases of seborrheic dermatitis can be effectively managed with significant improvement in symptoms and quality of life.