What are the treatment options for seborrheic dermatitis of the scalp?

Treatment Options for Seborrheic Dermatitis of the Scalp

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

First-Line Treatment Options

Antifungal Therapy

• Ketoconazole 2% cream is FDA-approved for seborrheic dermatitis and should be applied to affected areas twice daily for four weeks or until clinical clearing 2
• Antifungal shampoos are recommended as first-line therapy for scalp seborrheic dermatitis 3
• Options include:
  • Ketoconazole shampoo 3, 4
  • Selenium sulfide shampoo 5
  • Pyrithione zinc shampoo 5

Anti-inflammatory Agents

• Topical corticosteroids are recommended for short-term use (up to 4 weeks) to control inflammation 6, 1
• Moderate potency (class 2-5) corticosteroids can be used for cases not responding to first-line therapy 6
• Caution must be exercised with topical corticosteroids to avoid skin atrophy, striae, and other adverse effects 6, 1

Second-Line Treatment Options

Alternative Topical Preparations

• Coal tar shampoos are recommended for seborrheic dermatitis involving the scalp 6, 7
• Sodium sulfacetamide preparations may be effective for scalp seborrheic dermatitis 5
• Terbinafine solution can be used as an alternative topical treatment 5

Systemic Treatments for Resistant Cases

• Oral antifungal agents like ketoconazole, itraconazole, or terbinafine may be preferred in widespread or resistant cases 8

Treatment Algorithm

1. Initial Therapy: Start with antifungal shampoo (ketoconazole, selenium sulfide, or pyrithione zinc) 2-3 times weekly 3, 4
2. For Moderate Cases: Add ketoconazole 2% cream to affected areas twice daily 2
3. For Inflammatory Flares: Add short-term topical corticosteroid (up to 4 weeks) 6, 1
4. For Resistant Cases: Consider coal tar preparations or oral antifungal therapy 6, 8

Special Considerations

• Gentle skin care with mild, non-soap cleansers and moisturizers helps reduce dryness and scaling in mild cases 1
• Emollients are most effective when applied after bathing to provide a surface lipid film that retards evaporative water loss 7
• Check for possible nutrient deficiencies (thyroid function, vitamin D, zinc, ferritin) that may exacerbate seborrheic dermatitis 6

Common Pitfalls and Caveats

• Avoid long-term use of topical corticosteroids, especially on the face, due to risk of skin atrophy, telangiectasia, and tachyphylaxis 1
• Watch for signs of contact dermatitis from topical preparations, particularly neomycin which causes reactions in 5-15% of patients 6, 7
• Distinguish seborrheic dermatitis from similar conditions like psoriasis, atopic dermatitis, and contact dermatitis, which require different treatment approaches 1
• If no clinical improvement is seen after the treatment period, the diagnosis should be reconsidered 2
• Secondary bacterial infection may occur and should be treated with appropriate antibiotics if present 1