What is the treatment for seborrhoeic 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

Topical Antifungals (Primary Therapy)

• Ketoconazole 2% cream is the mainstay of treatment for facial and body seborrheic dermatitis, applied twice daily for four weeks or until clinical clearing 2, 3
• Ketoconazole works by inhibiting Malassezia ovale (the causative yeast organism) and has both antifungal and anti-inflammatory properties 2, 4
• If no clinical improvement occurs after the treatment period, the diagnosis should be reconsidered 2

Topical Corticosteroids (Short-Term Adjunct)

• Use topical corticosteroids only for short durations to control acute inflammation and itching 1, 3
• Hydrocortisone can temporarily relieve itching associated with seborrheic dermatitis 5
• Avoid long-term corticosteroid use, especially on the face, due to risks of skin atrophy, telangiectasia, and tachyphylaxis 1
• Use the least potent preparation required to keep the condition under control 1

Scalp-Specific Treatment

Over-the-Counter Shampoos (Initial Therapy)

• Direct patients to initiate therapy with over-the-counter antifungal or medicated shampoos 3
• Coal tar preparations (1% strength preferred) can reduce inflammation and scaling in scalp seborrheic dermatitis 1

Prescription Shampoo Regimens

• Ketoconazole 2% shampoo twice weekly is highly effective for scalp involvement 6
• Combination therapy of clobetasol propionate 0.05% shampoo twice weekly alternating with ketoconazole 2% shampoo twice weekly provides superior efficacy and sustained effect for moderate to severe scalp disease 7
• This combination regimen is more effective than ketoconazole alone and maintains efficacy during maintenance phases 7

Supportive Care Measures

Gentle Skin Care

• Use mild, non-soap cleansers (dispersible creams as soap substitutes) to avoid removing natural lipids 1
• Apply emollients after bathing to provide a surface lipid film that retards water loss 1
• Use lukewarm water instead of hot water to prevent facial dryness 1
• Avoid alcohol-containing preparations on the face as they increase skin dryness 1

Moisturization

• Apply non-greasy moisturizers with urea or glycerin after bathing to maintain skin hydration 1
• Avoid greasy products that can inhibit absorption and promote superinfection 1

Management of Symptoms

Pruritus Control

• Antihistamines with sedative properties (cetirizine, loratadine, fexofenadina) can be useful as short-term adjuvants during severe flares with intense pruritus 1
• Avoid overuse of non-sedating antihistamines, which have little value in seborrheic dermatitis 1

Treatment for Resistant or Severe Cases

Systemic Antifungal Therapy

• Oral antifungals may be preferred when seborrheic dermatitis is widespread or unresponsive to topical therapy 4, 8
• Itraconazole: 200 mg/day for the first week of the month, then 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 with other systemic treatments 8

Additional Considerations

• Narrowband UVB phototherapy has shown efficacy in open, uncontrolled studies 1
• Ichthammol (1% in zinc ointment) or paste bandages may be useful for lichenified areas 1

Critical Pitfalls to Avoid

• Do not use neomycin in topical preparations due to risk of sensitization 1
• Distinguish seborrheic dermatitis from psoriasis, atopic dermatitis, and contact dermatitis, which require different treatment approaches 1
• Look for evidence of secondary bacterial infection (crusting, weeping) or herpes simplex infection (grouped, punched-out erosions) and treat appropriately with antibiotics if present 1
• Avoid undertreatment due to fear of steroid side effects—use appropriate potency for adequate duration, then discontinue 1