What is the treatment for sebhorreic dermatitis?

Treatment of Seborrheic Dermatitis

For seborrheic dermatitis, initiate treatment with topical ketoconazole 2% cream applied twice daily for 4 weeks, which serves as the primary antifungal agent targeting the underlying Malassezia yeast, and combine with a low-potency topical corticosteroid (such as hydrocortisone 1%) for short-term control of inflammation and itching. 1, 2, 3

First-Line Treatment Approach

Topical Antifungal Therapy

• Ketoconazole 2% cream is the cornerstone of treatment, applied twice daily to affected areas for 4 weeks or until clinical clearing 2, 3
• This directly addresses the Malassezia yeast overgrowth that drives the inflammatory response 3
• Ketoconazole gel 2% formulation offers once-daily application and is nearly invisible after application, which may improve adherence compared to cream 4

Anti-Inflammatory Agents (Short-Term Use Only)

• Add hydrocortisone 1% cream (or other low-potency topical corticosteroid) twice daily for rapid symptom control, but limit use to 2-4 weeks maximum 1, 5, 6
• For more significant erythema and inflammation on the face, prednicarbate cream 0.02% can be considered 1
• Critical caveat: Avoid long-term corticosteroid use, especially on the face, due to risks of skin atrophy, telangiectasia, and tachyphylaxis 1

The evidence shows comparable efficacy between ketoconazole 2% and hydrocortisone 1% monotherapy (81.6% vs 87.2% symptomatic improvement), but ketoconazole provides the added benefit of significantly reducing yeast counts 6. When used in combination, both agents address different aspects of the disease pathophysiology.

Scalp-Specific Treatment

Initial Therapy

• Start with over-the-counter antifungal shampoos containing ketoconazole, selenium sulfide, or zinc pyrithione 1, 3
• Apply shampoo, leave on scalp for 5-10 minutes before rinsing to allow adequate contact time 3

Moderate to Severe Scalp Disease

• For moderate to severe scalp seborrheic dermatitis, use clobetasol propionate 0.05% shampoo twice weekly alternating with ketoconazole 2% shampoo twice weekly 7
• This combination regimen (C2+K2) provides significantly greater efficacy than ketoconazole alone and maintains sustained effect during maintenance therapy 7
• After initial 4-week treatment phase, transition to ketoconazole shampoo once weekly for maintenance 7

Essential Supportive Skin Care Measures

Cleansing Practices

• 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
• Pat skin dry gently rather than rubbing 1

Moisturization Strategy

• Apply fragrance-free, non-greasy moisturizers containing urea (10%) 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 Products to Avoid

• Alcohol-containing preparations worsen facial dryness and should be avoided 1
• Harsh soaps and detergents strip natural skin lipids 1
• Topical acne medications (especially retinoids) may irritate and worsen the condition 1
• Products containing neomycin or bacitracin due to sensitization risk 1

Treatment Duration and Monitoring

• Facial/body seborrheic dermatitis: Treat for 4 weeks or until clinical clearing 2
• If no clinical improvement occurs after 4 weeks, reconsider the diagnosis 2
• Watch for secondary bacterial infection (crusting, weeping) or herpes simplex superinfection (grouped, punched-out erosions), which require specific antimicrobial treatment 1

Alternative and Adjunctive Therapies

For Refractory Cases

• Narrowband UVB phototherapy can be considered for recalcitrant cases not responding to topical therapy 1
• Do not apply moisturizers or topical products immediately before phototherapy as they create a bolus effect 1

Symptomatic Relief

• Oral antihistamines (cetirizine, loratadine, fexofenadina) for moderate to severe pruritus 1
• Topical polidocanol-containing lotions provide additional pruritic relief 1
• Lidocaine 5% patches or cream for pain associated with severe inflammation 8

Common Pitfalls to Avoid

• Undertreatment due to excessive fear of corticosteroid side effects - use appropriate potency for adequate duration (2-4 weeks), then taper 1
• Overuse of non-sedating antihistamines, which have limited value in seborrheic dermatitis 1
• Continuing topical corticosteroids beyond 4 weeks, especially on facial skin 1
• Failing to distinguish seborrheic dermatitis from psoriasis (look for well-demarcated, indurated plaques with thick silvery scale), atopic dermatitis (more intense pruritus with lichenification), or contact dermatitis (sharp demarcation corresponding to contact area) 1