What is the treatment for seborrheic dermatitis?

Treatment for 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 Treatments

Topical Antifungals

• 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 therapy reduces the number of Malassezia yeasts on the skin, leading to improvement in seborrheic dermatitis 3
• Other effective antifungal agents include bifonazole, itraconazole, terbinafine, butenafine, and ciclopirox 3

Topical Anti-inflammatory Agents

• Low-potency topical corticosteroids like hydrocortisone can temporarily relieve itching and inflammation associated with seborrheic dermatitis 4
• Calcineurin inhibitors (tacrolimus, pimecrolimus) are effective alternatives to corticosteroids, especially for facial use where steroid side effects are concerning 3, 5

Scalp Treatment

• Antifungal shampoos containing ingredients like ketoconazole, zinc pyrithione, or selenium sulfide are effective for scalp seborrheic dermatitis 6
• Coal tar preparations can be used to reduce inflammation and scaling in scalp seborrheic dermatitis 1
• Keratolytic shampoos containing salicylic acid or sulfur can help remove thick scales 6

Special Considerations

For Facial Seborrheic Dermatitis

• Avoid alcohol-containing preparations as they may increase skin dryness 1
• Use gentle, non-soap cleansers and light moisturizers formulated as creams or gel/creams 7
• Products with antimicrobial and anti-inflammatory ingredients such as zinc, piroctone olamine, and stearyl glycyrrhetinate may help prevent flare-ups 7

For Resistant Cases

• Narrowband UVB phototherapy has shown efficacy in seborrheic dermatitis in open, uncontrolled studies 8, 1
• Oral antifungal therapy (ketoconazole, itraconazole, or terbinafine) may be preferred for widespread or resistant seborrheic dermatitis 3
• Roflumilast foam is a newly approved topical treatment with potential to become a first-line option for resistant cases 5

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
• Avoid neomycin in topical preparations due to risk of sensitization 1
• Undertreatment due to fear of steroid side effects should be avoided 1
• Seborrheic dermatitis must be distinguished from similar conditions like psoriasis, atopic dermatitis, and contact dermatitis, which require different treatment approaches 1
• In people with darker skin, erythema may be less apparent, and postinflammatory pigmentary changes might present as hypopigmented, slightly scaly areas 6, 9
• Secondary bacterial infection may occur and should be treated with appropriate antibiotics if present 1

Treatment Algorithm

1. Start with gentle skin care using mild, non-soap cleansers and moisturizers for mild cases 1
2. For moderate cases, use topical antifungals (ketoconazole 2% cream twice daily) 2
3. For inflammatory lesions, add low-potency topical corticosteroids for short-term use 4
4. For facial involvement or when concerned about steroid side effects, use calcineurin inhibitors 3
5. For scalp involvement, use medicated shampoos containing antifungal agents or coal tar 1, 6
6. For resistant cases, consider narrowband UVB phototherapy or oral antifungal therapy 8, 3
7. For newer options in recalcitrant cases, consider roflumilast foam 5