What is the treatment for seborrheic dermatitis?

Treatment of Seborrheic Dermatitis

The treatment of seborrheic dermatitis should include topical antifungal medications to reduce Malassezia yeast along with topical anti-inflammatory medications to control inflammation and itching. 1

Pathophysiology and Clinical Presentation

Seborrheic dermatitis is a common inflammatory skin condition affecting sebaceous gland-rich areas of the skin, including:

• Scalp
• Face (especially nasolabial folds)
• Central chest
• Ears
• Eyebrows

It presents with:

• Greasy yellowish scaling
• Itching
• Secondary inflammation
• More pronounced in patients with Down syndrome, HIV infection, and Parkinson's disease 1

First-Line Treatment

Topical Antifungals

• Ketoconazole 2% cream or shampoo:
  • For facial/body involvement: Apply cream once daily to affected areas for 2-4 weeks 2
  • For scalp involvement: Use shampoo twice weekly for 2-4 weeks for initial treatment 3
  • For maintenance: Use shampoo once weekly to prevent relapse 3

Topical Anti-inflammatory Agents

• Low-potency corticosteroids (for short-term use only):
  • Hydrocortisone 1% cream: Apply to affected areas twice daily for short durations 4
  • Particularly useful for facial involvement where inflammation is prominent

Combination Approach

• Consider alternating or combining antifungal and anti-inflammatory treatments for optimal results
• For severe cases, use both agents but limit corticosteroid use to short periods

Skin Care Recommendations

• Use gentle, non-soap cleansers instead of regular soaps 1
• Apply moisturizers regularly to affected areas 1
• Avoid skin irritants, harsh chemicals, and alcohol-containing products 5
• Avoid excessive washing with hot water 1

Second-Line Treatments

For Resistant Cases

• Topical calcineurin inhibitors (tacrolimus, pimecrolimus):
  • Alternative to corticosteroids, especially for facial involvement
  • Useful when long-term therapy is needed 1

For Widespread or Severe Disease

• Consider oral antifungal therapy:
  • Ketoconazole or itraconazole may be effective 6
  • Reserved for extensive or resistant cases

Special Considerations

Scalp Seborrheic Dermatitis

• Antifungal shampoos are the mainstay of treatment 7
• Options include:
  • Ketoconazole 2% shampoo (most effective) 3
  • Zinc pyrithione shampoo
  • Selenium sulfide shampoo
  • Coal tar or salicylic acid preparations

Common Pitfalls to Avoid

1. Overuse of topical corticosteroids: Can lead to skin atrophy, telangiectasia, and tachyphylaxis
2. Inadequate treatment duration: Treatment should continue for at least 2-4 weeks for full effect
3. Failure to implement maintenance therapy: Regular use of antifungal shampoo (once weekly) can prevent relapse 3
4. Misdiagnosis: Seborrheic dermatitis can mimic other conditions like psoriasis, atopic dermatitis, or contact dermatitis

Treatment Algorithm

1. Initial treatment (2-4 weeks):

   • Ketoconazole 2% cream applied once daily to affected areas of face/body
   • Ketoconazole 2% shampoo used twice weekly for scalp involvement
   • Short-term use of hydrocortisone 1% for inflammatory lesions

2. Maintenance therapy:

   • Weekly ketoconazole 2% shampoo for scalp
   • As-needed application of antifungal cream for body/facial flares

3. For resistant cases:

   • Consider topical calcineurin inhibitors
   • Consider oral antifungal therapy for widespread disease

Remember that seborrheic dermatitis is typically a chronic condition requiring ongoing management rather than a condition that can be permanently cured.