Treatment Options for Seborrheic Dermatitis
First-Line Treatment Approach
The most effective treatment for seborrheic dermatitis combines topical antifungal medications (particularly ketoconazole) to reduce Malassezia yeast with topical anti-inflammatory agents to control inflammation and itching. 1
Topical Antifungal Therapy (Primary Treatment)
- Ketoconazole 2% cream should be applied to affected areas twice daily for four weeks or until clinical clearing for seborrheic dermatitis of the face and body 2, 3
- For scalp involvement, antifungal shampoos containing ketoconazole, selenium sulfide, or pyrithione zinc should be initiated as first-line therapy 3, 4
- Treatment with topical ketoconazole is the mainstay of therapy because seborrheic dermatitis results from an inflammatory response to Malassezia yeast 3
Topical Anti-Inflammatory Therapy (Short-Term Adjunct)
- Hydrocortisone cream can be used for inflammatory lesions to temporarily relieve itching associated with seborrheic dermatitis 5, 6
- Topical corticosteroids should only be used for short durations due to risk of skin atrophy, telangiectasia, and tachyphylaxis, especially on the face 1, 3
- The least potent corticosteroid preparation required to control the condition should be used 1
Supportive Care Measures
Skin Barrier Management
- Gentle cleansing with mild, non-soap cleansers is recommended for mild seborrheic dermatitis 1
- Oil-in-water creams or ointments should be applied at least once daily to maintain skin barrier function and reduce dryness 5
- Avoid alcohol-containing preparations on facial seborrheic dermatitis as they increase skin dryness 1, 5
- Hot showers and excessive soap use should be avoided as they exacerbate dryness 5
Symptomatic Relief
- For moderate to severe pruritus, oral antihistamines with sedative properties (cetirizine, loratadina, fexofenadina) can be used as short-term adjuvants during severe flares 1, 5
- Non-sedating antihistamines have little value in controlling pruritus and should be avoided 5
Advanced Treatment Options
Combination Therapy for Scalp Involvement
- Clobetasol propionate 0.05% shampoo twice weekly alternating with ketoconazole 2% shampoo twice weekly provides significantly greater efficacy than ketoconazole alone for moderate to severe scalp seborrheic dermatitis 7
- This combination regimen sustains efficacy during maintenance phases better than either agent alone 7
- Coal tar preparations can reduce inflammation and scaling in scalp seborrheic dermatitis 1
Systemic Therapy for Severe or Refractory Cases
When topical treatments fail, oral antifungal therapy may be considered:
- Itraconazole: 200 mg/day for the first week of the month, followed by 200 mg/day for the first 2 days monthly for 2-11 months 8
- Terbinafine: 250 mg/day either continuously for 4-6 weeks or intermittently (12 days per month) for 3 months 8
- Fluconazole: 50 mg/day for 2 weeks or 200-300 mg weekly for 2-4 weeks 8
- Ketoconazole oral therapy is associated with more relapses compared to other systemic antifungals 8
Alternative Therapies
- Narrowband UVB phototherapy has shown efficacy in open, uncontrolled studies 1
- Topical calcineurin inhibitors (pimecrolimus, tacrolimus) should only be used for short durations due to possible adverse effects 3, 9
Critical Pitfalls to Avoid
- Never use neomycin-containing topical preparations due to high risk of sensitization 1
- Avoid long-term topical corticosteroid use, particularly on the face 1
- Do not undertreat due to fear of steroid side effects, but also avoid overuse 1
- Distinguish seborrheic dermatitis from psoriasis, atopic dermatitis, and contact dermatitis, which require different treatment approaches 1
- Watch for secondary bacterial infection (crusting, weeping) or herpes simplex infection (grouped, punched-out erosions), which require appropriate antimicrobial therapy 1, 5