What are the treatment options for seborrheic dermatitis?

Treatment Options 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 cream 2% is FDA-approved for seborrheic dermatitis and should be applied to affected areas twice daily for four weeks or until clinical clearing 2
• Ketoconazole works by impairing the synthesis of ergosterol, a vital component of fungal cell membranes, and reducing Malassezia ovale, though the latter mechanism hasn't been definitively proven 2
• Antifungal shampoos containing ketoconazole, selenium sulfide, or pyrithione zinc are effective for scalp seborrheic dermatitis and should be used regularly for maintenance therapy 3, 4
• For scalp seborrheic dermatitis, ketoconazole shampoo has shown significant improvement in irritation and scaling with low relapse rates and minimal side effects 5

Anti-inflammatory Agents

• Topical corticosteroids (such as hydrocortisone) can be used for inflammatory lesions but should be limited to short-term use, especially on the face, due to risks of skin atrophy, telangiectasia, and tachyphylaxis 1, 6
• Use the least potent corticosteroid preparation required to keep the condition under control 1
• Topical calcineurin inhibitors can be considered as steroid-sparing agents for facial seborrheic dermatitis 7

Gentle Skin Care

• Use dispersible creams as soap substitutes to cleanse the skin, as soaps and detergents remove natural lipids from skin surface 1
• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss 1
• Oil-in-water creams or ointments are preferred over alcohol-containing lotions or gels, especially for facial seborrheic dermatitis 1, 6
• Avoid hot showers and excessive use of soaps that can exacerbate dryness 6

Special Considerations

For Scalp Seborrheic Dermatitis

• Coal tar preparations (1% solution) can be used to reduce inflammation and scaling 1
• Patients should be directed to initiate therapy with over-the-counter antifungal shampoos before considering prescription options 4
• Medicated shampoos should replace regular shampoos in affected patients 8

For Resistant Cases

• For recalcitrant disease, consider referral to a dermatologist for further evaluation 6
• Roflumilast foam is a newly approved topical treatment with potential to become a first-line option for moderate-to-severe cases 7
• Systemic treatments exist as second- and third-line options for moderate-to-severe or recalcitrant cases 7

Managing Secondary Complications

• If bacterial infection is suspected (indicated by crusting or weeping), appropriate antibiotics should be considered 9, 1
• For herpes simplex infection (suggested by grouped, punched-out erosions), oral acyclovir should be given early 9, 6
• For severe itching, oral antihistamines with sedative properties may be useful as short-term adjuvant therapy, though non-sedating antihistamines have little value 9, 6

Treatment Pitfalls to Avoid

• Undertreatment due to fear of steroid side effects 9
• Long-term use of topical corticosteroids, especially on the face 1
• Using neomycin-containing topical preparations due to risk of sensitization 1
• Failing to distinguish seborrheic dermatitis from similar conditions like psoriasis, atopic dermatitis, and contact dermatitis 1
• Using greasy products that can inhibit the absorption of wound exudate and promote superinfection 1
• Continuing treatment without reassessing diagnosis if no clinical improvement is seen after the recommended treatment period 2