What are the treatment options for scalp eczema?

Treatment Options for Scalp Eczema

For scalp eczema, the most effective treatment approach is a combination of potent topical corticosteroids for short-term use (2-4 weeks maximum) and antifungal shampoos, particularly those containing ketoconazole, for both treatment and maintenance. 1, 2, 3

First-Line Treatment Options

Topical Corticosteroids

• High-potency corticosteroids (such as clobetasol propionate) are recommended for moderate to severe scalp eczema 2
  • Apply twice daily (morning and night) for acute flares
  • Limit treatment to 2 consecutive weeks
  • Do not exceed 50 mL/week to avoid hypothalamic-pituitary-adrenal (HPA) axis suppression 2
  • Not recommended for children under 12 years 2
• Medium to low-potency corticosteroids for milder cases or maintenance therapy 1

Antifungal Treatments

• Ketoconazole 2% shampoo:
  • Treatment phase: Use twice weekly for 2-4 weeks 4
  • Maintenance phase: Use once weekly to prevent relapse 4
  • Shown to be 88% effective in clearing scalp seborrheic dermatitis 4
• Other antifungal options include:
  • Selenium sulfide shampoo
  • Pyrithione zinc shampoo
  • Ciclopirox shampoo 5, 6

Second-Line Treatment Options

Calcineurin Inhibitors

• Consider for short-term use when corticosteroids are contraindicated or ineffective 1
• Helps avoid steroid-related side effects such as skin atrophy

Phototherapy

• Consider for chronic or recurrent cases unresponsive to topical treatments 1
• Oral PUVA (Psoralen + UVA) has shown superior efficacy to UVB 1

Treatment Algorithm

1. Initial Treatment (Acute Phase):

   • High-potency topical corticosteroid solution (e.g., clobetasol) twice daily for 2 weeks maximum 2
   • Concurrent antifungal shampoo (ketoconazole 2%) twice weekly 4

2. Maintenance Phase:

   • Reduce corticosteroid to medium/low potency or discontinue
   • Continue ketoconazole shampoo once weekly for prevention 4
   • For persistent cases, alternate between medicated shampoo and regular shampoo

3. For Refractory Cases:

   • Consider referral to dermatology for:
     • Patch testing to identify potential allergens 1
     • Consideration of systemic therapies for severe cases 1
     • Phototherapy options 1

Important Considerations and Pitfalls

• Avoid prolonged use of high-potency corticosteroids as this can lead to:

  • Skin atrophy
  • Telangiectasias
  • Striae
  • HPA axis suppression 1, 2

• Differentiate between types of scalp eczema:

  • Seborrheic dermatitis (most common, associated with Malassezia yeast) 3
  • Atopic dermatitis
  • Contact dermatitis (allergic or irritant) 7

• For seborrheic dermatitis specifically:

  • Antifungal agents are particularly important as Malassezia yeast plays a key role 3
  • Relapse is common without maintenance therapy 4

• Infection prevention:

  • Monitor for secondary bacterial infection
  • Treat with appropriate antibiotics if infection occurs 8
  • Consider antiseptic washes for erosive lesions 1

By following this structured approach to scalp eczema treatment, focusing on appropriate corticosteroid use for inflammation and antifungal agents for underlying yeast, most patients will experience significant improvement with minimal adverse effects.