What are the prescription therapies for seborrheic dermatitis?

Prescription Therapy for Seborrheic Dermatitis

For seborrheic dermatitis, initiate treatment with topical ketoconazole 2% cream applied twice daily for four weeks, which combines antifungal activity against Malassezia yeast with the anti-inflammatory properties needed to control this condition. 1

First-Line Prescription Options

Topical Antifungals (Primary Treatment)

• Ketoconazole 2% cream is FDA-approved specifically for seborrheic dermatitis and should be applied twice daily for four weeks or until clinical clearing 1
• Ketoconazole provides dual benefit through antifungal activity against Malassezia species and inherent anti-inflammatory properties 2
• Alternative topical antifungals include ciclopirox, miconazole, and clotrimazole for mild-to-moderate facial or body involvement 3

Topical Corticosteroids (Short-Term Adjunct)

• Mild-to-moderate potency corticosteroids can be used for significant erythema and inflammation, but only for short durations 3, 4
• For facial involvement, use prednicarbate cream 0.02% when more significant inflammation is present 5
• Critical caveat: Avoid long-term corticosteroid use on the face due to risk of skin atrophy, telangiectasia, and tachyphylaxis 5, 4

Location-Specific Prescription Approaches

Scalp Seborrheic Dermatitis

• Antifungal shampoos containing ketoconazole should be used long-term as maintenance therapy 4
• Topical corticosteroids can be added short-term for acute flares 4
• Coal tar preparations reduce inflammation and scaling in scalp involvement 5

Facial Seborrheic Dermatitis

• Avoid alcohol-containing preparations as they increase facial dryness 5
• Use mild, non-soap cleansers and apply non-greasy moisturizers with urea or glicerina after bathing 5
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) can be considered off-label for facial involvement when corticosteroid use is contraindicated 3, 2
• Lithium succinate or gluconate preparations are alternative prescription options for facial areas 3

Second-Line Prescription Therapies

Systemic Antifungals (Severe/Resistant Cases)

• Oral itraconazole or terbinafine should be considered for widespread or treatment-resistant seborrheic dermatitis 3, 2
• Oral ketoconazole is effective but reserved for severe cases due to hepatotoxicity concerns 2
• Systemic therapy reduces Malassezia yeast burden throughout affected areas 2

Phototherapy

• Narrowband UVB phototherapy has demonstrated efficacy in open studies for recalcitrant cases not responding to topical therapy 5
• Avoid applying moisturizers or topical products immediately before phototherapy sessions as they create a bolus effect 5

Treatment Algorithm by Severity

Mild-to-Moderate Disease

1. Start with topical ketoconazole 2% cream twice daily 1
2. Add short-term mild-to-moderate potency corticosteroid if significant inflammation present 3
3. Transition to maintenance with antifungal therapy alone once controlled 4

Severe or Resistant Disease

1. Continue topical antifungal therapy 3
2. Add systemic antifungal (itraconazole or terbinafine) 3, 2
3. Consider narrowband UVB phototherapy if inadequate response 5

Critical Pitfalls to Avoid

• Never use neomycin-containing topical preparations due to high risk of sensitization 5
• Do not continue topical corticosteroids beyond short-term use, especially on facial skin 5, 4
• Avoid greasy products that can inhibit absorption and promote superinfection 5
• Do not undertreat due to fear of steroid side effects—use appropriate potency for adequate duration then discontinue 5

Adjunctive Prescription Measures

• Oral antihistamines (cetirizine, loratadina, fexofenadina) can be prescribed for moderate-to-severe pruritus 5
• Topical polidocanol-containing lotions provide additional pruritus relief 5
• For fissuring: propylene glycol 50% in water applied 30 minutes under plastic occlusion nightly, followed by hydrocolloid dressing 5

Monitoring and Reassessment

• If no clinical improvement occurs after four weeks of ketoconazole therapy, redetermine the diagnosis 1
• Consider alternative diagnoses including psoriasis (well-demarcated indurated plaques with thick silvery scale), atopic dermatitis (more intense pruritus with lichenification), or contact dermatitis (sharp demarcation) 5
• For treatment-refractory cases, consider cutaneous T-cell lymphoma and obtain biopsy looking for atypical lymphocytes 5