What is the treatment for seborrhoeic dermatitis?

Treatment for Seborrheic Dermatitis

The most effective treatment for seborrheic dermatitis combines topical antifungal medications (particularly ketoconazole 2% cream) with short-term topical corticosteroids to control inflammation, while avoiding long-term steroid use especially on the face. 1

First-Line Treatment Approach

Scalp Seborrheic Dermatitis

• Start with over-the-counter antifungal shampoos containing ketoconazole, selenium sulfide 1%, or coal tar preparations 1, 2, 3
• Apply antifungal shampoos and leave on scalp for several minutes before rinsing to maximize contact time 2
• For prescription-strength treatment, use ketoconazole 2% shampoo or topical solutions/foams 3
• Thick, scaly areas require keratolytic shampoos to remove scale buildup before antifungal penetration 3

Face and Body Seborrheic Dermatitis

• Apply ketoconazole 2% cream twice daily for four weeks or until clinical clearing 4
• For significant erythema and inflammation, add a mild topical corticosteroid (such as prednicarbate cream 0.02%) for short-term use only 1
• Avoid alcohol-containing preparations on the face as they worsen dryness 1

Essential Skin Care Measures

Daily Maintenance

• Use mild, non-soap cleansers with pH 5 neutral formulations and tepid (not hot) water 1
• Apply non-greasy emollients with urea or glycerin after bathing to provide a surface lipid film that prevents water loss 1
• Pat skin dry rather than rubbing to avoid irritation 1

Products to Avoid

• Harsh soaps and detergents that strip natural skin lipids 1
• Greasy or occlusive creams that can promote folliculitis 1
• Topical acne medications (especially retinoids) due to their drying effects 1

Treatment Duration and Monitoring

Treatment timelines vary by location:

• Facial and body lesions: 2-4 weeks of twice-daily ketoconazole 2% cream 4
• Scalp involvement: Ongoing maintenance with antifungal shampoos 2, 3
• If no clinical improvement after 4 weeks, reconsider the diagnosis 4

Second-Line and Adjunctive Therapies

When First-Line Treatment Fails

• Calcineurin inhibitors (tacrolimus or pimecrolimus) can be used as steroid-sparing alternatives, though they may cause more adverse effects than steroids initially 1, 5
• Lithium salts show efficacy and may be more effective than azoles for total clearance 5
• Narrowband UVB phototherapy for recalcitrant cases not responding to topical therapy 1

Oral Therapy for Severe Cases

• 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 6
• Terbinafine 250 mg/day continuously for 4-6 weeks or intermittently (12 days per month) for 3 months 6
• Fluconazole 50 mg/day for 2 weeks or 200-300 mg weekly for 2-4 weeks 6
• Avoid ketoconazole for oral therapy due to higher relapse rates compared to other oral antifungals 6

Symptomatic Relief

• Oral antihistamines (cetirizine, loratadine, fexofenadina) for moderate to severe pruritus 1
• Topical polidocanol-containing lotions for additional pruritus relief 1

Critical Pitfalls to Avoid

Corticosteroid Misuse

• Never use topical corticosteroids long-term on the face due to risk of skin atrophy, telangiectasia, and tachyphylaxis 1
• Undertreatment due to steroid phobia leads to inadequate disease control 1
• Mild (class I-II) and strong (class III-IV) steroids show comparable short-term efficacy, so start with mild potency 5

Diagnostic Errors

• Distinguish from psoriasis (well-demarcated indurated plaques with thick silvery scale vs. greasy yellow scales) 1
• Rule out atopic dermatitis (more intense pruritus, lichenification, flexural involvement) 1
• Consider contact dermatitis if sharp demarcation corresponds to contact area 1
• If refractory to standard treatment, biopsy to exclude cutaneous T-cell lymphoma 1

Infection Complications

• Monitor for secondary bacterial infection (crusting, weeping) requiring appropriate antibiotics 1
• Watch for herpes simplex infection (grouped, punched-out erosions) needing antiviral therapy 1

Special Populations

Neonatal Seborrheic Dermatitis (Cradle Cap)

• Typically self-resolves by 6 months of age 3
• Mild cases: treat conservatively with mineral oil to loosen scale and gentle combing 3
• Severe cases overlapping with atopic dermatitis: use topical antifungals or mild topical corticosteroids 3

Darker Skin Tones

• Erythema may be less apparent; look for postinflammatory hypopigmentation as a presenting sign 3