What are the treatment options for seborrheic dermatitis?

Treatment of Seborrheic Dermatitis

The most effective treatment for seborrheic dermatitis combines topical antifungal agents (particularly ketoconazole) to reduce Malassezia yeast with topical anti-inflammatory agents 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 excellent response in 88% of patients with moderate to severe disease 2
• After initial clearing, continue ketoconazole 2% shampoo once weekly for prophylaxis to prevent relapse (reduces recurrence from 47% to 19%) 2
• Alternative medicated shampoos include selenium sulfide, pyrithione zinc, or coal tar preparations if ketoconazole is unavailable 3, 4

Facial and Body Seborrheic Dermatitis

• Apply ketoconazole 2% cream once daily to affected areas for 2-4 weeks 5, 6
• For facial involvement specifically, avoid alcohol-containing preparations as they increase skin dryness 1
• Use gentle, non-soap cleansers and apply non-greasy moisturizers with urea or glycerin after bathing 1

Anti-Inflammatory Adjuncts

Topical Corticosteroids

• Use low-potency topical corticosteroids (such as 1% hydrocortisone) for short-term control of inflammation only 7, 6
• Apply the least potent preparation required to control symptoms 1
• Avoid long-term use, especially on the face, due to risk of skin atrophy, telangiectasia, and tachyphylaxis 1
• Limit overall treatment duration with corticosteroid-containing preparations 4

Alternative Anti-Inflammatory Options

• Topical calcineurin inhibitors (pimecrolimus, tacrolimus) can be used short-term as steroid-sparing agents 8, 6
• Coal tar solution (1% strength preferred) can reduce inflammation and scaling, particularly for scalp involvement 4, 1

Adjunctive Measures

Skin Care Fundamentals

• Cleanse affected areas with mild, pH-neutral synthetic detergents rather than soap, which removes natural lipids 1
• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss 1
• Use lukewarm water instead of hot water to prevent additional dryness 1

Symptom Management

• For moderate to severe pruritus, use sedating antihistamines (not non-sedating types) as short-term adjuvants during flares 4, 1
• Oral antihistamines (cetirizine, loratadine, fexofenadina) can be used for intense itching 1

Treatment of Secondary Complications

Bacterial Superinfection

• Look for clinical signs: crusting, weeping, or increased erythema 1
• Treat with appropriate systemic antibiotics (flucloxacillin for S. aureus, erythromycin for penicillin allergy) 4

Fissuring

• Apply propylene glycol 50% in water for 30 minutes under plastic occlusion nightly, followed by hydrocolloid dressing 1

Refractory Cases

Systemic Antifungal Therapy

• For widespread or treatment-resistant disease, consider oral ketoconazole, itraconazole, or terbinafine 8, 3
• This approach reduces yeast burden systemically and may be preferred when topical therapy fails 8

Alternative Therapies

• Narrowband UVB phototherapy has shown efficacy in open studies 1
• Topical terbinafine solution or sodium sulfacetamide can be used as alternatives 3

Critical Pitfalls to Avoid

• Do not use neomycin-containing topical preparations due to high sensitization risk 1
• Avoid greasy topical products that inhibit exudate absorption and promote superinfection 1
• Do not rely on non-sedating antihistamines, which have little value in seborrheic dermatitis 4, 1
• Distinguish seborrheic dermatitis from psoriasis, atopic dermatitis, and contact dermatitis, which require different treatment approaches 1
• Address patient fears about topical steroids to prevent undertreatment, while emphasizing short-term use only 4, 1

Treatment Duration and Follow-Up

• Facial and body lesions typically require 2-4 weeks of antifungal therapy 5
• If no clinical improvement occurs after the treatment period, redetermine the diagnosis 5
• Maintain long-term prophylaxis with weekly ketoconazole shampoo for scalp involvement to prevent relapse 2