What are the treatment options for managing seborrheic dermatitis?

Management of Seborrheic Dermatitis

First-Line Treatment Strategy

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

Scalp Seborrheic Dermatitis

For scalp involvement, start with ketoconazole 2% shampoo or cream applied to affected areas. 2, 3

• Apply ketoconazole 2% cream twice daily for four weeks or until clinical clearing 2
• If no improvement after four weeks, reconsider the diagnosis 2
• Alternative antifungal shampoos include selenium sulfide 1%, ciclopirox, or povidone-iodine 1, 4
• For thick, scaly areas, use keratolytic agents (coal tar 1% solution preferred over crude coal tar) to reduce scaling before applying antifungals 1, 5

Facial Seborrheic Dermatitis

For facial involvement, apply ketoconazole 2% cream twice daily, avoiding alcohol-containing preparations that worsen dryness. 1, 2

• For significant erythema and inflammation, add prednicarbate cream 0.02% or other mild-to-moderate potency corticosteroids 1, 3
• Avoid long-term corticosteroid use on the face due to risk of skin atrophy, telangiectasia, and tachyphylaxis 1
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) are effective alternatives for maintenance therapy without steroid-related side effects 3, 4
• Lithium succinate/gluconate preparations provide additional anti-inflammatory options 3, 4

Body Seborrheic Dermatitis

• Apply ketoconazole 2% cream once daily to affected areas 2
• Treatment duration is typically two weeks to reduce recurrence risk 2
• Mild-to-moderate potency corticosteroids can be added for significant inflammation 3

Essential Supportive Skin Care Measures

Use mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes to preserve the skin's natural lipid barrier. 1

• Wash with tepid (not hot) water, as hot water removes natural lipids and worsens dryness 1
• Apply fragrance-free moisturizers containing petrolatum or mineral oil immediately after bathing to damp skin 1
• Pat skin dry with clean towels rather than rubbing 1
• Avoid alcohol-containing preparations on the face, as they increase dryness 1
• Avoid greasy or occlusive products that can promote folliculitis 1

Treatment for Resistant or Severe Cases

For recalcitrant cases not responding to topical therapy, consider narrowband UVB phototherapy. 1

• Phototherapy has demonstrated effectiveness in open studies for seborrheic dermatitis 1
• Avoid applying moisturizers or topical products immediately before phototherapy, as they create a bolus effect 1
• Systemic antifungal therapy (terbinafine, itraconazole) is reserved for widespread lesions or cases refractory to topical treatment 3, 4

Critical Pitfalls to Avoid

Never use neomycin-containing topical preparations due to high risk of sensitization. 1

• Avoid long-term topical corticosteroids, especially on the face 1
• Do not undertreat due to fear of steroid side effects—use the least potent preparation required to control the condition 1
• Distinguish seborrheic dermatitis from psoriasis (well-demarcated, indurated plaques with thick silvery scale), atopic dermatitis (more intense pruritus with lichenification), and contact dermatitis (sharp demarcation corresponding to contact area) 1
• Watch for secondary bacterial infection (crusting, weeping) or herpes simplex superinfection (grouped, punched-out erosions), which require specific antimicrobial treatment 1

Adjunctive Therapy for Symptoms

• For moderate-to-severe pruritus, use oral antihistamines (cetirizine, loratadine, fexofenadina) 1
• Sedating antihistamines can be useful as short-term adjuvants during severe flares with intense pruritus 1
• Non-sedating antihistamines have little value in seborrheic dermatitis and should be avoided 1
• Topical polidocanol-containing lotions provide additional relief for pruritus 1

Maintenance Strategy

After achieving clinical clearing, transition to maintenance therapy with ketoconazole shampoo or intermittent antifungal applications to prevent recurrence. 1

• Keep nails short to minimize trauma from scratching 1
• Continue gentle skin care with non-soap cleansers and regular moisturization 1
• Apply hypoallergenic sunscreen daily (at least SPF 30, UVA/UVB protection) with zinc oxide or titanium dioxide 1

Special Considerations for Infants

Neonatal seborrheic dermatitis (cradle cap) typically self-resolves by 6 months of age. 5

• Mild cases can be treated conservatively with mineral oil to loosen scale and gentle combing 5
• More severe cases may require topical antifungals or mild topical corticosteroids 5
• Baby shampoos enriched with emollient agents and vegetable oils are usually sufficient 3