What is the treatment for seborrheic dermatitis of the scalp?

Treatment of Seborrheic Dermatitis of the Scalp

For scalp seborrheic dermatitis, start with topical antifungal shampoos (ketoconazole, selenium sulfide, or pyrithione zinc) used 2-3 times weekly, combined with short-term topical corticosteroids for moderate-to-severe inflammation. 1, 2, 3

First-Line Treatment Approach

Antifungal Shampoos

• Ketoconazole shampoo is the primary first-line treatment, targeting the Malassezia yeast that drives inflammation in seborrheic dermatitis 4, 5
• Selenium sulfide 1-2.5% shampoo is equally effective: massage 1-2 teaspoonfuls into wet scalp, allow to remain for 2-3 minutes, rinse thoroughly, and repeat application 6
• Pyrithione zinc shampoo represents another validated first-line option 7, 5
• Apply antifungal shampoos 2-3 times weekly on alternating days for initial control, then transition to maintenance dosing 8

Application Technique

• Leave shampoo on scalp for 2-3 minutes (ketoconazole) or 2-3 minutes with repeat application (selenium sulfide) to allow adequate contact time 6
• Rinse thoroughly after each application 6
• Wash hands well after treatment 6

Second-Line Treatment for Inadequate Response

Topical Corticosteroids

• Use moderate-potency corticosteroids (class 2-5) such as clobetasol propionate 0.05% shampoo for short periods only (up to 4 weeks maximum) when first-line antifungals fail to control inflammation 2, 3
• Avoid long-term corticosteroid use on the scalp due to risk of skin atrophy, striae, telangiectasia, and tachyphylaxis 1, 3

Coal Tar Preparations

• Coal tar shampoos (1% strength preferred) reduce inflammation and scaling when antifungals alone are insufficient 1, 2, 3
• Be aware that coal tar may cause folliculitis, irritation, and staining of skin and clothing 3

Adjunctive Supportive Measures

Scalp Care Practices

• Use mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes to preserve natural lipid barrier 1, 3
• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss 3
• Use tepid water instead of hot water, which worsens symptoms by removing natural lipids 1
• Pat scalp dry rather than rubbing vigorously 1

For Thick, Adherent Scale

• Apply keratolytic agents to loosen dense scale before shampooing 4
• Coal tar preparations can help reduce thick scaling 1, 2

Critical Pitfalls to Avoid

Medication-Related Errors

• Never use neomycin-containing topical preparations, as 5-15% of patients develop contact dermatitis to this ingredient 1, 2
• Avoid alcohol-containing preparations that increase skin dryness 1
• Do not use greasy or occlusive products that can promote folliculitis 1

Treatment Duration Errors

• Undertreatment due to fear of corticosteroid side effects is common—use adequate potency for short duration rather than prolonged weak corticosteroids 1
• Overuse of topical corticosteroids leads to skin atrophy and rebound flares 3

Monitoring and Special Considerations

Watch for Complications

• Look for secondary bacterial infection (crusting, weeping) requiring antibiotic treatment 1, 3
• Check for grouped, punched-out erosions suggesting herpes simplex superinfection 1
• Monitor for contact dermatitis from topical preparations 2, 3

Evaluate Contributing Factors

• Check thyroid function, vitamin D, zinc, and ferritin levels, as deficiencies may exacerbate seborrheic dermatitis 2
• Consider that seborrheic dermatitis is more severe in patients with Down syndrome, HIV infection, and Parkinson's disease 2, 3

Maintenance Strategy

• Once controlled, continue antifungal shampoos 1-2 times weekly for long-term maintenance 5
• Taper corticosteroids gradually rather than stopping abruptly 1
• Consider switching to ketoconazole shampoo for maintenance if initially using other agents 1