What is the recommended treatment for seborheic dermatitis?

Treatment of Seborrheic Dermatitis

The recommended first-line treatment for seborrheic dermatitis includes topical antifungal agents such as ketoconazole 2% cream applied twice daily for four weeks, along with mild corticosteroids for inflammation control. This approach targets both the underlying Malassezia fungal colonization and inflammatory response that characterize this condition 1, 2.

Pathophysiology and Clinical Presentation

Seborrheic dermatitis is a common chronic inflammatory skin disorder affecting areas rich in sebaceous glands, particularly:

• Scalp (dandruff)
• Face (especially nasolabial folds, eyebrows, glabella)
• Ears (including ear canals)
• Central chest
• Body folds

The condition is associated with:

• Malassezia yeast overgrowth
• Sebaceous gland activity
• Abnormal immune response
• Possible genetic predisposition

Clinical features include:

• Erythematous patches/plaques
• Greasy or yellowish scaling
• Mild to moderate pruritus
• In infants: "cradle cap" with yellowish, scaly patches

Treatment Algorithm

First-line Treatment:

1. Topical Antifungals:

   • Ketoconazole 2% cream applied twice daily for 4 weeks 1
   • Alternatives: ciclopirox, miconazole, clotrimazole 2, 3

2. Topical Anti-inflammatories:

   • Mild potency corticosteroids (hydrocortisone 1-2.5%) for short-term use 4, 5
   • Apply twice daily for 1-2 weeks to control inflammation

3. Scalp Treatment:

   • Medicated shampoos containing:
     • Ketoconazole 2%
     • Selenium sulfide
     • Pyrithione zinc
     • Use 2-3 times weekly, leaving on scalp for 3-5 minutes before rinsing 5, 6

Maintenance Therapy:

• After initial control, reduce antifungal application to 1-2 times weekly
• Use gentle, non-soap cleansers
• Continue medicated shampoos 1-2 times weekly for scalp involvement

For Resistant Cases:

1. Topical Calcineurin Inhibitors:

   • Tacrolimus 0.1% or pimecrolimus 1% cream (off-label)
   • Particularly useful for facial involvement where prolonged steroid use is concerning 2, 5

2. Systemic Treatment:

   • Oral antifungals (itraconazole, terbinafine) for severe or widespread disease 2, 3
   • Short courses (1-2 weeks) may be needed

3. Phototherapy:

   • Narrowband UVB may be beneficial for resistant cases 7, 2

Special Considerations

Facial Involvement:

• Avoid potent corticosteroids
• Limit mild corticosteroids to short courses (1-2 weeks)
• Consider topical calcineurin inhibitors for steroid-sparing effect

Infantile Seborrheic Dermatitis:

• Usually self-limiting
• Gentle baby shampoos with emollients
• Medical device shampoos containing piroctone olamine, bisabolol 2
• Avoid prolonged corticosteroid use

Adjunctive Measures:

• Gentle skin care with pH-neutral cleansers
• Avoid irritants, alcohol-based products
• Non-pharmacological products with zinc, piroctone olamine may help prevent recurrences 8

Monitoring and Follow-up

• Evaluate response after 2-4 weeks of treatment
• If no improvement, reconsider diagnosis (possible psoriasis, eczema, tinea, or other dermatoses)
• For recurrent cases, maintenance therapy with weekly antifungal applications may be necessary

Common Pitfalls to Avoid

1. Overuse of corticosteroids: Can lead to skin atrophy, telangiectasia, and tachyphylaxis
2. Inadequate treatment duration: Full 4-week course of antifungals often needed for complete resolution
3. Misdiagnosis: Seborrheic dermatitis can be confused with psoriasis, eczema, or tinea faciei
4. Neglecting maintenance therapy: Seborrheic dermatitis is chronic and often recurs without ongoing management

The combination of antifungal and anti-inflammatory treatments addresses both the underlying cause and symptoms, providing effective control of seborrheic dermatitis while minimizing side effects from prolonged corticosteroid use.