What is the treatment of seborrheic dermatitis?

Treatment of Seborrheic Dermatitis

The most effective treatment for seborrheic dermatitis combines topical antifungal medications to reduce Malassezia yeast with topical anti-inflammatory agents to control inflammation and itching. 1

First-Line Topical Treatments

• Antifungal agents are the cornerstone of therapy due to the role of Malassezia yeasts in seborrheic dermatitis pathogenesis:

  • Ketoconazole 2% cream applied twice daily for four weeks is FDA-approved for seborrheic dermatitis 2
  • Clinical improvement may be seen fairly soon after treatment begins, but treatment should continue for the full recommended duration to prevent recurrence 2
  • If a patient shows no clinical improvement after the treatment period, the diagnosis should be reconsidered 2

• Topical corticosteroids help reduce inflammation and relieve symptoms:

  • Low-potency corticosteroids like hydrocortisone are effective for temporary relief of itching and inflammation 3
  • Avoid long-term use of topical corticosteroids, especially on the face, due to risk of skin atrophy, telangiectasia, and tachyphylaxis 1

• Gentle skin care is essential for all patients:

  • Use mild, non-soap cleansers to avoid removing natural lipids from skin surface 1
  • Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss 1
  • Avoid alcohol-containing preparations on the face as they may increase skin dryness 1

Treatment Based on Location

Facial Seborrheic Dermatitis

• Low-potency corticosteroids for short-term use (1-2 weeks) 1
• Ketoconazole 2% cream twice daily for four weeks 2
• Calcineurin inhibitors (tacrolimus, pimecrolimus) as steroid-sparing agents 4
• Non-steroidal topical products containing zinc PCA, piroctone olamine, and stearyl glycyrrhetinate have shown excellent response in patients with mild to moderate facial seborrheic dermatitis 5

Scalp Seborrheic Dermatitis

• Antifungal shampoos containing ketoconazole, zinc pyrithione, selenium sulfide, or ciclopirox 6
• For thick, scaly areas, use keratolytic shampoos containing salicylic acid or coal tar 1
• For severe cases, topical corticosteroid solutions, foams, or oils can be used 6

Treatment for Resistant Cases

• For severe or widespread seborrheic dermatitis unresponsive to topical therapy, oral antifungals may be considered:
  • Itraconazole 200 mg/day for the first week of the month followed by 200 mg/day for the first 2 days for 2-11 months 7
  • Terbinafine 250 mg/day either continuously (4-6 weeks) or intermittently (12 days per month) for 3 months 7
  • Fluconazole 50 mg/day for 2 weeks or 200-300 mg weekly for 2-4 weeks 7
  • Ketoconazole 200 mg daily for 4 weeks 7

Special Considerations

• Secondary bacterial infection may occur in seborrheic dermatitis and should be treated with appropriate antibiotics if present 1
• Look for evidence of clinical infection such as crusting, weeping, or grouped, punched-out erosions (suggesting herpes simplex infection) 1
• Distinguish seborrheic dermatitis from similar conditions like psoriasis, atopic dermatitis, and contact dermatitis, which may require different treatment approaches 1
• Avoid undertreatment due to fear of steroid side effects 1
• Avoid overuse of non-sedating antihistamines, which have little value in seborrheic dermatitis 1

Maintenance Therapy

• After successful initial treatment, maintenance therapy is often necessary to prevent relapse:
  • Twice weekly application of ketoconazole shampoo or cream 4
  • Regular use of zinc-containing cleansers 8
  • Specific cleansers, moisturizers, and sunscreens formulated as light creams or gel/creams should be recommended to all patients with facial seborrheic dermatitis 8