What is the treatment for seborrhic dermatitis?

Treatment of Seborrheic Dermatitis

The most effective treatment for seborrheic dermatitis combines topical antifungal agents (ketoconazole 2% cream) with short-term topical corticosteroids to reduce Malassezia yeast and control inflammation. 1

First-Line Pharmacological Treatment

Topical Antifungals (Primary Therapy)

• Apply ketoconazole 2% cream twice daily for 4 weeks or until clinical clearing 2
• Ketoconazole targets the underlying Malassezia yeast that drives the inflammatory response 3, 4
• For scalp involvement, use antifungal shampoos containing ketoconazole 2%, selenium sulfide 1%, or pyrithione zinc 1, 5, 6
• Alternative antifungal options include terbinafine solution or ciclopirox if ketoconazole is not tolerated 4, 6

Topical Corticosteroids (Short-Term Anti-Inflammatory)

• Use low-potency corticosteroids (hydrocortisone 1-2.5%) for facial and body lesions, applied twice daily for up to 2-4 weeks maximum 1, 7, 8
• For scalp involvement not responding to first-line therapy, moderate-potency corticosteroids (class 2-5) can be used for up to 4 weeks 5
• Avoid long-term corticosteroid use, especially on the face, due to risk of skin atrophy, telangiectasia, and tachyphylaxis 1

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, as hot water removes natural lipids and worsens dryness 1
• Pat skin dry with clean towels rather than rubbing 1

Moisturization Strategy

• Apply fragrance-free, alcohol-free moisturizers containing urea (5-10%), petrolatum, or mineral oil immediately after bathing to damp skin 1
• Reapply moisturizer every 3-4 hours and after each face washing 1
• Avoid alcohol-containing preparations on the face as they worsen dryness 1
• Avoid greasy or occlusive products that can promote folliculitis 1

Sun Protection

• Apply hypoallergenic sunscreen daily (at least SPF 30 with UVA/UVB protection containing zinc oxide or titanium dioxide) 1
• Wear protective clothing and hats 1

Treatment Algorithm by Severity

Mild Disease

• Start with gentle skin care measures and antifungal shampoos for scalp involvement 1, 3
• Add ketoconazole 2% cream twice daily if skin care alone is insufficient 2

Moderate Disease

• Initiate ketoconazole 2% cream twice daily 2
• Add low-potency topical corticosteroid (hydrocortisone 1-2.5%) twice daily for 2-4 weeks to control inflammation 1, 7
• Taper corticosteroid once inflammation is controlled 1

Severe or Refractory Disease

• Consider moderate-potency corticosteroids for short duration (up to 4 weeks) 5
• Evaluate for secondary bacterial infection (look for crusting, weeping, or grouped punched-out erosions suggesting herpes simplex) and treat with appropriate antibiotics if present 1
• Consider narrowband UVB phototherapy for cases not responding to topical therapy 1
• Check for nutrient deficiencies (thyroid function, vitamin D, zinc, ferritin) that may exacerbate the condition 5

Common Pitfalls to Avoid

• Do not use over-the-counter anti-acne medications (especially retinoids), as they irritate and worsen the condition 1
• Avoid products containing neomycin due to high sensitization risk (5-15% of patients develop contact dermatitis) 1, 5
• Do not undertreat due to fear of corticosteroid side effects, but also avoid prolonged corticosteroid use 1
• Avoid harsh soaps, detergents, and frequent washing with hot water 1
• Do not apply moisturizers immediately before phototherapy if prescribed, as they create a bolus effect 1

Maintenance Therapy

• Once cleared, consider switching to ketoconazole shampoo for maintenance if scalp is affected 1
• Continue gentle skin care practices and moisturization indefinitely 1
• Monitor for flare-ups and reinitiate treatment early 1