From the Guidelines
Seborrheic dermatitis should be treated with topical antifungal medications to reduce the amount of yeast present and topical anti-inflammatory medications to reduce inflammation and itch. This approach is based on the understanding that seborrheic dermatitis is a common condition affecting the ears, scalp, central face, and other sebaceous areas of the skin, presenting with greasy yellowish scaling, itching, and secondary inflammation from Malassezia yeast 1.
Diagnosis
The diagnosis of seborrheic dermatitis involves identifying the characteristic greasy yellowish scaling, itching, and secondary inflammation, particularly in areas with high sebaceous gland activity. It's essential to differentiate seborrheic dermatitis from other skin conditions that may mimic its symptoms, such as psoriasis and discoid lupus erythematosus, which have distinct skin lesions and often involve other areas of the skin 1.
Treatment
Treatment of seborrheic dermatitis focuses on reducing the yeast population and inflammation. Topical antifungal medications are used to decrease the amount of Malassezia yeast on the skin, while topical anti-inflammatory medications help to reduce itch and inflammation. For mild cases, over-the-counter anti-dandruff shampoos containing ingredients like ketoconazole, selenium sulfide, or zinc pyrithione can be effective for scalp involvement. For facial and body involvement, topical antifungal creams or mild corticosteroid creams can be applied to affected areas.
Management Considerations
- Identify and manage triggers: Stress, hormonal changes, and seasonal shifts can exacerbate seborrheic dermatitis. Maintaining a consistent skincare routine and avoiding triggers when possible can help in long-term management.
- Monitor for complications: Secondary skin infections can occur, particularly if the condition is not adequately managed.
- Consider underlying conditions: Seborrheic dermatitis can be more pronounced in patients with certain underlying conditions, such as Down syndrome, HIV infection, and Parkinson's disease 1.
Key Points for Treatment
- Use topical antifungal medications to reduce yeast population.
- Apply topical anti-inflammatory medications to reduce inflammation and itch.
- Identify and manage triggers to prevent flare-ups.
- Monitor for secondary infections and manage them promptly if they occur.
From the FDA Drug Label
Seborrheic dermatitis: Ketoconazole Cream 2% should be applied to the affected area twice daily for four weeks or until clinical clearing. If a patient shows no clinical improvement after the treatment period, the diagnosis should be redetermined. The diagnosis of seborrheic dermatitis is not explicitly stated in the provided drug labels, but the treatment is:
- Ketoconazole Cream 2% should be applied to the affected area
- Twice daily
- For four weeks or until clinical clearing
- If no improvement is seen after the treatment period, the diagnosis should be re-determined 2 The therapeutic effect of ketoconazole in seborrheic dermatitis is postulated to be due to the reduction of M. ovale, but this has not yet been proven 2
From the Research
Diagnosis of Seborrheic Dermatitis
- Seborrheic dermatitis is a clinical diagnosis based on the location and appearance of the lesions 3
- The skin changes are thought to result from an inflammatory response to a common skin organism, Malassezia yeast 3
Treatment of Seborrheic Dermatitis
- Topical antifungals and corticosteroids are the mainstay of treatment for seborrheic dermatitis 4, 5, 3
- Oral therapies can be prescribed in severe or unresponsive cases, including itraconazole, terbinafine, fluconazole, ketoconazole, pramiconazole, prednisone, and isotretinoin 4
- Antifungal shampoos (long-term) and topical corticosteroids (short-term) can be used as second-line agents for treatment of scalp seborrheic dermatitis 3
- Combination therapy of topical corticosteroids and antifungals can be effective in treating moderate to severe scalp seborrheic dermatitis 5
Specific Treatment Options
- Itraconazole dosing regimen for seborrheic dermatitis: 200 mg/day for the first week of the month followed by 200 mg/day for the first 2 days for 2-11 months 4
- Terbinafine dosing regimen for seborrheic dermatitis: 250 mg/day either as a continuous (4-6 weeks) or as an intermittent regimen (12 days per month) for 3 months 4
- Fluconazole dosing regimen for seborrheic dermatitis: 50 mg/day for 2 weeks or 200-300 mg weekly for 2-4 weeks 4, 6, 7
- Ketoconazole dosing regimen for seborrheic dermatitis: 200 mg daily for 4 weeks 4, 5