What are the treatment options for seborreic dermatitis?

Treatment Options for Seborrheic Dermatitis

Topical antifungal agents, particularly ketoconazole cream 2% applied twice daily for four weeks, are the mainstay of treatment for seborrheic dermatitis, with topical corticosteroids recommended for short-term use to manage inflammation and itching. 1, 2

First-Line Treatments

Topical Antifungals

• Ketoconazole cream 2% should be applied to affected areas twice daily for four weeks 1
• If no clinical improvement is seen after the treatment period, the diagnosis should be reconsidered 1
• Antifungal agents work by reducing Malassezia yeasts on the skin, which are thought to contribute to seborrheic dermatitis through an inflammatory response 2, 3

Emollients and Moisturizers

• Regular use of moisturizers helps maintain skin barrier function and reduces dryness 4
• Oil-in-water creams or ointments are preferred over alcohol-containing lotions or gels 4
• Apply moisturizers at least once daily to affected areas 4

Topical Corticosteroids

• Hydrocortisone and other mild topical corticosteroids can temporarily relieve itching and inflammation 5
• Should be used for short durations only to avoid potential adverse effects such as skin atrophy 2
• For inflammatory lesions, consider topical steroids such as hydrocortisone cream 4

Scalp Seborrheic Dermatitis Treatment

Medicated Shampoos

• Antifungal shampoos containing ketoconazole, selenium sulfide, or pyrithione zinc are effective for scalp seborrheic dermatitis 2, 6
• For moderate to severe scalp seborrheic dermatitis, a combination of clobetasol propionate 0.05% shampoo alternating with ketoconazole 2% shampoo has shown superior efficacy 7
• Treatment regimen: Use antifungal shampoo 2-3 times weekly initially, then reduce to once weekly for maintenance 2, 7

Second-Line Treatments

Combination Therapy

• For resistant cases, combining topical antifungals with short-term topical corticosteroids is more effective than monotherapy 7
• For scalp seborrheic dermatitis, alternating antifungal shampoo with corticosteroid shampoo provides sustained efficacy 7

Oral Antifungals

• For widespread or severe seborrheic dermatitis unresponsive to topical therapy, oral antifungals may be considered 3, 8
• Options include:
  • Itraconazole: 200 mg/day for the first week of the month, followed by 200 mg/day for the first 2 days of subsequent months 8
  • Terbinafine: 250 mg/day either continuously (4-6 weeks) or intermittently (12 days per month for 3 months) 8
  • Fluconazole: 50 mg/day for 2 weeks or 200-300 mg weekly for 2-4 weeks 8

Management of Special Situations

Secondary Infection

• If bacterial infection is suspected, appropriate antibiotics should be considered 4
• For herpes simplex infection (eczema herpeticum), oral acyclovir should be given early 4

Seborrheic Dermatitis with Pruritus

• For severe itching, oral antihistamines with sedative properties may be useful as short-term adjuvant therapy 4
• Non-sedating antihistamines have little value in controlling pruritus associated with seborrheic dermatitis 4
• Topical polidocanol cream can help relieve itching 4

Treatment Pitfalls and Considerations

• Avoid hot showers and excessive use of soaps that can exacerbate dryness 4
• Long-term use of potent topical corticosteroids should be avoided due to risk of skin atrophy 2
• If no improvement is seen after 4 weeks of treatment, reconsider the diagnosis 1
• Patients with recalcitrant disease should be referred to a dermatologist for further evaluation 4
• Contact dermatitis from topical medications (particularly neomycin) can complicate treatment and should be considered if worsening occurs 4

Maintenance Therapy

• After initial control, reduce frequency of antifungal applications to prevent recurrence 7
• Weekly use of antifungal shampoo can help maintain remission for scalp seborrheic dermatitis 7
• Regular use of moisturizers should be continued to prevent dryness 4