What is the treatment for seborrheic dandruff?

Treatment for Seborrheic Dermatitis (Dandruff)

The most effective treatment for seborrheic dermatitis combines topical antifungal medications (particularly ketoconazole 2% shampoo) to reduce Malassezia yeast with short-term topical anti-inflammatory agents to control inflammation and itching. 1

First-Line Treatment: Antifungal Therapy

Ketoconazole 2% Shampoo (Preferred Agent)

• Apply ketoconazole 2% shampoo twice weekly for 2-4 weeks for initial treatment of scalp seborrheic dermatitis. 2, 3
• Ketoconazole 2% demonstrates superior efficacy compared to zinc pyrithione 1%, achieving 73% improvement in total dandruff severity score versus 67% at 4 weeks, with significantly lower recurrence rates. 3
• For maintenance therapy after initial clearing, continue ketoconazole 2% shampoo once weekly to prevent relapse—this reduces recurrence to 19% compared to 47% with placebo. 4
• The medication works through both antifungal and anti-inflammatory mechanisms against Malassezia yeasts. 5

For Facial and Body Seborrheic Dermatitis

• Apply ketoconazole 2% cream twice daily for four weeks or until clinical clearing. 2
• Avoid alcohol-containing preparations on the face as they worsen dryness. 1

Second-Line and Adjunctive Treatments

Short-Term Topical Corticosteroids

• Use low-potency corticosteroids (such as prednicarbate cream 0.02%) for significant erythema and inflammation. 1
• Limit corticosteroid use to short periods only—avoid long-term application, especially on the face, due to risk of skin atrophy, telangiectasia, and tachyphylaxis. 1, 6

Alternative Medicated Shampoos

• Selenium sulfide 1% shampoo has demonstrated efficacy alongside ketoconazole. 1
• Coal tar preparations (1% strength preferred) can reduce inflammation and scaling in scalp seborrheic dermatitis. 1, 6
• Zinc pyrithione 1% shampoo is effective but less so than ketoconazole 2%. 3

Essential Supportive Skin Care Measures

Cleansing Practices

• Use mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes to preserve natural skin lipids. 1
• Wash with tepid (not hot) water—hot water worsens symptoms by removing natural lipids. 1
• Pat skin dry with clean towels rather than rubbing. 1

Moisturization Strategy

• Apply fragrance-free, non-greasy moisturizers containing urea or glycerin immediately after bathing to damp skin. 1
• Reapply moisturizer every 3-4 hours and after each face washing. 1
• Avoid greasy or occlusive products that can promote folliculitis. 1

Critical Pitfalls to Avoid

• Do not use neomycin-containing topical preparations due to high sensitization risk. 1
• Avoid topical acne medications (especially retinoids) as they worsen dryness and irritation. 1
• Do not apply moisturizers immediately before phototherapy if prescribed, as they create a bolus effect. 1
• Watch for secondary bacterial infection (crusting, weeping) or herpes simplex superinfection (grouped, punched-out erosions) which require specific antimicrobial treatment. 1, 6

Treatment Algorithm for Recalcitrant Cases

• If no clinical improvement occurs after 4 weeks of ketoconazole therapy, redetermine the diagnosis. 2
• Consider narrowband UVB phototherapy for cases not responding to topical therapy. 1
• For widespread disease, oral antifungals (ketoconazole, itraconazole, or terbinafine) may be preferred. 5
• Rule out alternative diagnoses: psoriasis (well-demarcated plaques with thick silvery scale), atopic dermatitis (more intense pruritus with lichenification), contact dermatitis (sharp demarcation), or cutaneous T-cell lymphoma (if refractory to standard treatment). 1