How to treat seborrheic dermatitis?

Treatment of Seborrheic Dermatitis

For seborrheic dermatitis, the first-line treatment is topical ketoconazole 2% cream applied twice daily to affected areas for four weeks. 1 This antifungal agent targets Malassezia yeast, which plays a key role in the pathophysiology of seborrheic dermatitis.

Treatment Algorithm

First-line Treatments:

1. Facial and Body Seborrheic Dermatitis:

   • Topical antifungal agents:
     • Ketoconazole 2% cream applied twice daily for four weeks 1
     • If no improvement after four weeks, reassess the diagnosis 1

2. Scalp Seborrheic Dermatitis:

   • Antifungal shampoos (used regularly as maintenance therapy):
     • Ketoconazole shampoo
     • Selenium sulfide shampoo
     • Pyrithione zinc shampoo 2, 3
   • Apply to affected areas, leave on for 5 minutes before rinsing

Second-line Treatments:

1. For inflammatory flares:

   • Topical corticosteroids (short-term use only):
     • Hydrocortisone cream for facial seborrheic dermatitis 4
     • Higher potency corticosteroids for scalp involvement
     • Limit use to 1-2 weeks to avoid side effects such as skin atrophy 2, 5

2. For resistant cases:

   • Calcineurin inhibitors (tacrolimus, pimecrolimus)
     • Particularly useful for facial involvement
     • Can be used for longer periods than corticosteroids 5
   • Lithium salts have shown effectiveness in clinical trials 5

Special Considerations

Scalp Management:

• For thick, scaly plaques (seborrheic scales), use keratolytic shampoos before antifungal treatment 3
• Apply mineral oil to loosen scales, followed by gentle combing, especially in cases of cradle cap in infants 3

Maintenance Therapy:

• After clearing, continue with regular use of antifungal shampoos to prevent recurrence
• Seborrheic dermatitis is chronic and relapsing; long-term management is often necessary 2, 3

Evidence Quality and Considerations

The recommendation for ketoconazole 2% cream is based on FDA-approved labeling 1, which specifically indicates twice daily application for four weeks in seborrheic dermatitis. This is supported by research showing that antifungal agents targeting Malassezia yeast are effective in treating seborrheic dermatitis 2, 6.

Topical corticosteroids like hydrocortisone are FDA-approved for seborrheic dermatitis 4, but should be used cautiously and for short durations due to potential adverse effects. A Cochrane review found that topical steroids are effective but should be used judiciously 5.

Common Pitfalls to Avoid

• Overuse of corticosteroids: Extended use can lead to skin atrophy, telangiectasias, and striae 7
• Inadequate treatment duration: Stopping treatment too soon may lead to rapid recurrence
• Misdiagnosis: If no improvement occurs after four weeks of treatment, reconsider the diagnosis 1
• Neglecting maintenance therapy: Seborrheic dermatitis is chronic and often requires ongoing management to prevent recurrence 3

Treatment Modifications

• For widespread disease: Consider oral antifungal therapy (ketoconazole, itraconazole, or terbinafine) 6
• For patients with darker skin tones: Be aware that erythema may be less apparent, and post-inflammatory pigmentary changes might be more prominent 3
• For severe or refractory cases: Consider referral to a dermatologist for alternative therapies or to confirm diagnosis 7