What is the treatment for seborrheic dermatitis?

Treatment for Seborrheic Dermatitis

For seborrheic dermatitis, start with topical ketoconazole 2% cream applied twice daily for 4 weeks, combined with gentle skin care using non-soap cleansers and emollients. 1, 2

First-Line Treatment Approach

Topical Antifungal Therapy (Primary Treatment)

• Apply ketoconazole 2% cream twice daily to affected areas for 4 weeks or until clinical clearing, as this addresses the underlying Malassezia yeast overgrowth 2, 3
• If no improvement after 4 weeks, redetermine the diagnosis 2
• For scalp involvement, use antifungal shampoos (ketoconazole 2%, selenium sulfide 1%, or coal tar preparations) as maintenance therapy 1, 3

Topical Anti-Inflammatory Agents (Short-Term Adjunct)

• Add low-potency topical corticosteroids (hydrocortisone 1% or prednicarbate 0.02%) for significant erythema and inflammation 1, 4, 5
• Use corticosteroids for limited periods only (not exceeding 2-4 weeks), especially on the face, due to risks of skin atrophy, telangiectasia, and tachyphylaxis 1
• Apply twice daily initially, then taper as inflammation improves 6

Essential Supportive Skin Care

• Use mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes to preserve natural skin lipids 1
• Apply emollients immediately after bathing to damp skin to create a surface lipid film that prevents water loss 6, 1
• Avoid alcohol-containing preparations, particularly on the face, as they worsen dryness 1
• Use tepid (not hot) water for cleansing 1

Treatment Algorithm by Severity

Mild Seborrheic Dermatitis

• Start with gentle cleansers and emollients alone 1
• Add ketoconazole 2% cream twice daily if no improvement within 1-2 weeks 2, 3

Moderate Seborrheic Dermatitis

• Begin with ketoconazole 2% cream twice daily 2
• Add low-potency topical corticosteroid for 1-2 weeks if significant inflammation present 1, 5
• Continue ketoconazole for full 4-week course 2

Severe or Refractory Cases

• Consider narrowband UVB phototherapy for cases not responding to topical therapy 1
• Oral antifungals may be warranted: itraconazole 200 mg/day for first week of month, then 200 mg/day for first 2 days monthly for 2-11 months 7
• Alternative oral options include terbinafine 250 mg/day for 4-6 weeks or fluconazole 50 mg/day for 2 weeks 7

Critical Pitfalls to Avoid

Medication-Related Errors

• Never use potent or very potent corticosteroids on the face due to high risk of adverse effects 1
• Avoid neomycin-containing preparations due to sensitization risk 1
• Do not use non-sedating antihistamines as they provide no benefit 6
• Avoid greasy or occlusive products that can promote folliculitis 1

Diagnostic Considerations

• Look for secondary bacterial infection (crusting, weeping) requiring antibiotics—flucloxacillin for S. aureus 6, 1
• Watch for herpes simplex superinfection (grouped, punched-out erosions) requiring acyclovir 6, 1
• Distinguish from psoriasis (thicker silvery scales, well-demarcated plaques), atopic dermatitis (more intense pruritus, flexural involvement), and contact dermatitis (sharp demarcation) 1

Maintenance Strategy

• After initial 4-week treatment course, consider intermittent ketoconazole application (1-2 times weekly) to prevent recurrence 3
• Continue gentle skin care and emollient use indefinitely 1
• For scalp involvement, maintain with antifungal shampoo 1-2 times weekly 1, 3
• Keep nails short to minimize trauma from scratching 1

Special Considerations

Facial Seborrheic Dermatitis

• Use prednicarbate 0.02% cream (lower potency) rather than stronger corticosteroids 1
• Strictly avoid alcohol-containing products 1
• Apply moisturizers every 3-4 hours and after each face washing 1

Scalp Involvement

• Coal tar solution 1% can reduce inflammation and scaling 1
• Selenium sulfide 1% shampoo is effective alongside ketoconazole 1
• Apply treatment not more than twice daily 6