Treatment for Seborrheic Dermatitis
The most effective treatment for seborrheic dermatitis combines topical antifungal medications (primarily ketoconazole 2% cream) with low-potency topical corticosteroids (hydrocortisone 1%) to simultaneously reduce Malassezia yeast colonization and control inflammation. 1
First-Line Treatment Algorithm
Initial Therapy (Weeks 1-4)
For facial and body involvement:
- Apply ketoconazole 2% cream twice daily for 4 weeks or until clinical clearing 2
- For significant erythema and inflammation, add hydrocortisone 1% cream applied once or twice daily for no more than 2-4 weeks 1, 3
- Use mild, pH-neutral (pH 5) non-soap cleansers with tepid water 1
- Apply fragrance-free moisturizers containing petrolatum or mineral oil immediately after bathing to damp skin 1
For scalp involvement:
- Apply ketoconazole 2% cream or use ketoconazole shampoo 1
- Alternative options include selenium sulfide 1% shampoo or coal tar solution 1% 1
- Apply treatments no more than twice daily 1
Critical Safety Considerations
Avoid these common pitfalls:
- Never use topical corticosteroids on the face beyond 2-4 weeks due to high risk of skin atrophy, telangiectasia, tachyphylaxis, and acneiform/rosacea-like eruptions 1
- Avoid alcohol-containing preparations as they increase facial dryness 1
- Avoid greasy or occlusive products that can promote folliculitis 1
- Avoid neomycin-containing preparations due to sensitization risk 1
- Do not use hot water; use tepid water instead 1
Maintenance Therapy
After initial clearing:
- Transition to ketoconazole shampoo for maintenance if scalp is affected 1
- Continue gentle skin care with dispersible creams as soap substitutes to preserve natural skin lipids 1
- Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss 1
- Reapply moisturizer every 3-4 hours and after each face washing 1
Adjunctive Measures
Essential supportive care:
- Keep nails short to minimize trauma from scratching 1
- Pat skin dry with clean towels rather than rubbing 1
- Apply hypoallergenic sunscreen daily (at least SPF 30 with zinc oxide or titanium dioxide) 1
- Avoid topical acne medications (especially retinoids) as they worsen dryness 1
For moderate to severe pruritus:
- Use sedating antihistamines (cetirizina, loratadina, fexofenadina) as short-term adjuvants during severe flares 1
- Avoid non-sedating antihistamines as they provide no benefit 1
Alternative First-Line Options
If ketoconazole is unavailable or not tolerated:
- Coal tar preparations (1% strength preferred) to reduce inflammation and scaling 1
- Selenium sulfide 1% shampoo 1
- Topical calcineurin inhibitors for facial involvement when corticosteroid use is contraindicated 4, 5
Second-Line Therapy for Recalcitrant Cases
For cases not responding to topical therapy after 4 weeks:
- Consider narrowband UVB phototherapy (demonstrated efficacy in open studies) 1
- Avoid applying moisturizers or topical products immediately before phototherapy as they create a bolus effect 1
- Systemic antifungals (ketoconazole, itraconazole, or terbinafine) reserved for widespread lesions or refractory cases 4, 5
Monitoring for Complications
Watch for secondary infections requiring specific treatment:
- Bacterial superinfection (Staphylococcus aureus): Look for crusting, weeping, or increased erythema; treat with flucloxacillin or appropriate antibiotics 1
- Herpes simplex superinfection: Look for grouped, punched-out erosions; treat with acyclovir 1
Differential Diagnosis Considerations
Before initiating treatment, distinguish seborrheic dermatitis from:
- Psoriasis: Well-demarcated, indurated plaques with thick silvery scale (not greasy yellow scales); personal/family history of psoriasis 1
- Atopic dermatitis: More intense pruritus, lichenification, flexural involvement, history of atopy 1
- Contact dermatitis: Sharp demarcation corresponding to contact area 1
- Cutaneous T-cell lymphoma: Consider if refractory to standard treatment; requires biopsy 1