What are the treatment options for seborrheic dermatitis?

Treatment of Seborrheic Dermatitis

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

First-Line Treatment Approach

For Scalp Involvement

• Apply antifungal shampoos containing ketoconazole, selenium sulfide, or pyrithione zinc as initial therapy 2, 3
• Ketoconazole 2% cream should be applied to affected scalp areas twice daily for four weeks or until clinical clearing 4
• Coal tar shampoos serve as an effective alternative for scalp seborrheic dermatitis 2
• For thick, scaly areas, use keratolytic shampoos and lotions to remove adherent scale 3

For Facial and Body Involvement

• Ketoconazole 2% cream applied twice daily for four weeks is the mainstay antifungal treatment 4, 5
• Avoid alcohol-containing preparations on the face as they increase skin dryness 1
• Use gentle, non-soap cleansers and apply moisturizers after bathing to provide a surface lipid film that retards evaporative water loss 1

Second-Line Treatment Options

When First-Line Therapy Fails

• Moderate potency (class 2-5) topical corticosteroids for short periods (up to 4 weeks) to control inflammation 2
• Hydrocortisone topical preparations can temporarily relieve itching and inflammation associated with seborrheic dermatitis 6
• Calcineurin inhibitor cream or ointment for facial involvement when corticosteroids are contraindicated 3, 5

For Recalcitrant Cases

• Narrowband UVB phototherapy has demonstrated efficacy in open studies for cases not responding to topical therapy 1
• Avoid applying moisturizers or topical products immediately before phototherapy as they create a bolus effect 1

Critical Pitfalls to Avoid

Corticosteroid-Related Complications

• Never use topical corticosteroids long-term, especially on the face, due to risk of skin atrophy, telangiectasia, and tachyphylaxis 1
• Undertreatment due to fear of steroid side effects should be avoided; use the least potent preparation required to control the condition 1

Product Selection Errors

• Avoid neomycin in topical preparations due to 5-15% risk of sensitization in patients with chronic conditions 1, 2
• Do not use greasy products as they inhibit absorption of wound exudate and promote superinfection 1
• Avoid overuse of non-sedating antihistamines, which have little value in seborrheic dermatitis 1

Adjunctive Management

Symptomatic Relief

• Oral antihistamines with sedative properties (cetirizina, loratadina, fexofenadina) can be useful as short-term adjuvants during severe flares with intense pruritus 1
• For moderate to severe itching, oral antihistamines may provide relief 1

Supportive Care

• Check for possible nutrient deficiencies (thyroid function, vitamin D, zinc, ferritin) that may exacerbate seborrheic dermatitis 2
• Look for evidence of secondary bacterial infection such as crusting, weeping, or grouped erosions, and treat with appropriate antibiotics if present 1

Differential Diagnosis Considerations

Always distinguish seborrheic dermatitis from similar conditions like psoriasis, atopic dermatitis, and contact dermatitis, which require different treatment approaches 1. In darker-skinned patients, erythema may be less apparent and postinflammatory pigmentary changes with hypopigmented, slightly scaly areas might be the presenting sign 3.