What is the treatment for seborrheic dermatitis?

Treatment of Seborrheic Dermatitis

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

First-Line Treatment Options

Scalp Treatment

• Use antifungal shampoos containing ketoconazole, selenium sulfide, or pyrithione zinc as first-line therapy for scalp seborrheic dermatitis 2, 3
• For thick, scaly areas, use keratolytic shampoos to help remove scales before applying medicated products 2
• Apply coal tar preparations to reduce inflammation and scaling in scalp seborrheic dermatitis 1
• Emollients should be applied after bathing to provide a surface lipid film that retards evaporative water loss 4

Facial and Body Treatment

• Apply ketoconazole cream 2% to affected areas twice daily for four weeks or until clinical clearing 5
• Use the least potent topical corticosteroid preparation required to control symptoms, such as hydrocortisone, for short-term use only 4, 6
• Avoid alcohol-containing preparations on the face as they may increase skin dryness 1
• Use dispersible creams as soap substitutes to cleanse the skin, as soaps and detergents remove natural lipids from skin surface 4

Second-Line Treatment Options

• For resistant cases, consider calcineurin inhibitors (pimecrolimus, tacrolimus) as steroid-sparing agents 2, 7
• Ichthammol (1% in zinc ointment) or paste bandages may be useful for lichenified areas 4
• Sedating antihistamines can be used as short-term adjuvants during severe flares with intense pruritus 4
• For widespread seborrheic dermatitis, oral antifungal therapy with ketoconazole, itraconazole, or terbinafine may be preferred 8

Treatment for Secondary Complications

• Look for evidence of clinical infection such as crusting or weeping 4
• Treat secondary bacterial infections with appropriate antibiotics:
  • Flucloxacillin for Staphylococcus aureus (most common pathogen) 4
  • Phenoxymethylpenicillin for B-hemolytic streptococci 4
  • Erythromycin for patients with penicillin allergy or resistance to flucloxacillin 4
• For herpes simplex infection (presenting as grouped, punched-out erosions), use oral acyclovir early in the course of disease 4

Important Considerations and Pitfalls

• Avoid long-term use of topical corticosteroids, especially on the face, due to risk of skin atrophy, telangiectasia, and tachyphylaxis 1, 7
• Non-sedating antihistamines have little value in seborrheic dermatitis 4
• If no clinical improvement is seen after the treatment period with antifungals, the diagnosis should be reconsidered 5
• Distinguish seborrheic dermatitis from similar conditions like psoriasis, atopic dermatitis, and contact dermatitis, which require different treatment approaches 1
• Undertreatment due to fear of steroid side effects should be avoided 4
• Avoid greasy products that can inhibit absorption of wound exudate and promote superinfection 1

Treatment Algorithm

1. Start with gentle skin care using mild, non-soap cleansers and moisturizers for mild cases 1
2. For scalp involvement: Use medicated antifungal shampoo 2-3 times weekly 2
3. For facial/body involvement: Apply ketoconazole cream 2% twice daily for four weeks 5
4. For inflammatory flares: Add short-term, low-potency topical corticosteroid 7
5. For resistant cases: Consider calcineurin inhibitors or oral antifungals 8, 2
6. For secondary infections: Add appropriate antibiotics based on clinical presentation 4
7. Reassess after 4 weeks; if no improvement, reconsider diagnosis 5