What are the first and second line treatment agents for seborrheic dermatitis?

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. The first line treatment agent for seborrheic dermatitis is ketoconazole.

• The FDA label does not specify a second line treatment agent for seborrheic dermatitis. 1

From the Research

For seborrheic dermatitis, first-line treatment typically involves topical antifungals and low-potency corticosteroids, with ketoconazole 2% shampoo or cream being an effective first-line antifungal option, as supported by 2.

First-Line Treatment Options

• Topical antifungals: ketoconazole 2% shampoo or cream applied to affected areas 2-3 times weekly for 4 weeks
• Low-potency corticosteroids: hydrocortisone 1% cream applied twice daily for 7-14 days to reduce inflammation
• Zinc pyrithione or selenium sulfide shampoos used 2-3 times weekly to control scalp disease

Second-Line Treatment Options

• Stronger topical corticosteroids: betamethasone valerate 0.1% for short-term use (5-7 days)
• Steroid-sparing agents: tacrolimus 0.1% or pimecrolimus 1% ointment twice daily for facial disease
• Oral antifungals: fluconazole 150-300mg weekly for 2-4 weeks for severe or recalcitrant cases, as mentioned in 3

Maintenance Therapy

• Antifungal shampoos 1-2 times weekly after initial clearance to prevent recurrence, as suggested by 4
• Patient counseling: seborrheic dermatitis is often chronic and may require long-term management to control symptoms and prevent recurrence, as noted in 5 and 6