What is the recommended treatment for seborrheic dermatitis?

Treatment of Seborrheic Dermatitis

The most effective treatment for seborrheic dermatitis combines topical antifungal medications (particularly ketoconazole) to reduce Malassezia yeast with short-term topical corticosteroids to control inflammation and itching. 1

First-Line Treatment Approach

Scalp Seborrheic Dermatitis

• Start with ketoconazole 2% shampoo twice weekly for 2-4 weeks, which produces an excellent response in 88% of patients 2
• After initial clearance, continue ketoconazole 2% shampoo once weekly for prophylaxis to prevent relapse (reduces recurrence from 47% to 19%) 2
• Apply ketoconazole shampoo and leave on scalp for several minutes before rinsing for optimal efficacy 3
• Coal tar shampoo preparations can be used as an alternative, though they may cause folliculitis, irritation, and staining 4, 5

Facial and Body Seborrheic Dermatitis

• Apply ketoconazole 2% cream twice daily for 4 weeks or until clinical clearing 6
• For rapid symptom control, add a low-potency topical corticosteroid (such as 1% hydrocortisone) twice daily for short-term use only (maximum 2 weeks on the face) 7, 3
• Avoid alcohol-containing preparations on the face as they increase dryness 1

Supportive Skin Care Measures

• Use mild, non-soap cleansers and lukewarm (not hot) water to prevent excessive dryness 1
• Apply non-greasy moisturizers containing urea or glycerin after bathing to maintain skin hydration 1
• Consider dispersible creams as soap substitutes, as traditional soaps remove natural protective lipids 1

Critical Pitfalls to Avoid

Corticosteroid Misuse

• Never use topical corticosteroids long-term, especially on the face, due to risks of skin atrophy, telangiectasia, and tachyphylaxis 1
• Use clobetasol propionate 0.05% shampoo for scalp only for short periods 4
• Undertreatment due to steroid phobia leads to inadequate disease control 1

Other Common Errors

• Avoid neomycin-containing topical preparations due to high sensitization risk 1
• Do not use non-sedating antihistamines routinely as they have little value in seborrheic dermatitis 1
• Watch for contact dermatitis from topical preparations themselves 4

When to Suspect Secondary Infection

Look for these specific clinical signs that indicate bacterial or viral superinfection requiring antimicrobial therapy 1:

• Crusting, weeping, or purulent exudate
• Grouped, punched-out erosions (suggesting herpes simplex)
• Pustules on examination
• Treat confirmed bacterial infection with appropriate systemic antibiotics 1

Refractory Cases

For widespread or treatment-resistant seborrheic dermatitis 8:

• Consider oral antifungal therapy with ketoconazole, itraconazole, or terbinafine
• Narrowband UVB phototherapy has shown efficacy in open studies 1
• Ensure correct diagnosis by distinguishing from psoriasis, atopic dermatitis, or contact dermatitis, which require different treatment approaches 1

Maintenance Therapy

After achieving clearance 2:

• Continue ketoconazole 2% shampoo once weekly indefinitely for scalp involvement
• Resume twice-weekly treatment promptly if symptoms recur
• Maintain gentle skin care and moisturization routines