What are the treatment options for seborrheic dermatitis?

Treatment of Seborrheic Dermatitis

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

First-Line Treatment Approach

For Scalp Involvement

• Apply ketoconazole 2% cream twice daily for four weeks or until clinical clearing 2
• Use shampoo, gel, solution, or foam formulations rather than ointments or creams for scalp application, as hair makes traditional formulations messy and difficult to use 1
• Alternative antifungal shampoos include selenium sulfide 1% or coal tar preparations to reduce inflammation and scaling 1, 3
• For thick, scaly areas, use keratolytic shampoos and lotions to remove scale 4

For Facial and Body Involvement

• Apply ketoconazole 2% cream twice daily for four weeks or until clinical clearing 2
• Avoid alcohol-containing preparations on the face as they increase skin dryness 1
• For mild cases, gentle skin care with mild, non-soap cleansers (pH 5 neutral formulations) and moisturizers to reduce dryness and scaling may be sufficient 1

Second-Line Anti-Inflammatory Treatment

When to Add Corticosteroids

• For significant erythema and inflammation not responding to antifungals alone, apply low-potency topical corticosteroids such as hydrocortisone 1% or prednicarbate 0.02% 1
• Limit corticosteroid use to 2-4 weeks maximum, especially on the face, due to risks of skin atrophy, telangiectasia, and tachyphylaxis 1, 3
• For scalp involvement, moderate potency (class 2-5) corticosteroids may be used for up to 4 weeks in cases not responding to first-line therapy 3

Alternative Anti-Inflammatory Options

• Calcineurin inhibitor cream or ointment can be used as a corticosteroid-sparing option for facial and body involvement 4, 5
• These should also be used for short durations only 6

Supportive Care Measures

Skin Cleansing and Moisturization

• Use mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes to preserve the skin's natural lipid barrier 1
• Apply fragrance-free moisturizers containing petrolatum or mineral oil immediately after bathing to damp skin 1
• Avoid hot water; use tepid water instead to prevent worsening symptoms 1
• Pat skin dry with clean towels rather than rubbing 1

Products to Avoid

• Avoid greasy or occlusive products that can promote folliculitis 1
• Avoid topical acne medications (especially retinoids) that may irritate and worsen the condition 1
• Avoid products containing neomycin due to high sensitization risk (5-15% of patients) 3
• Avoid harsh soaps and detergents that remove natural lipids from the skin surface 1

Management of Pruritus

• For moderate to severe itching, oral antihistamines with sedative properties (cetirizine, loratadine, fexofenadina) can be useful as short-term adjuvants during severe flares 1
• Avoid non-sedating antihistamines as they provide no benefit in seborrheic dermatitis 1
• Topical polidocanol-containing lotions can provide additional relief for pruritus 1

Treatment for Resistant Cases

Advanced Options

• Narrowband UVB phototherapy has shown efficacy in open studies and can be considered for recalcitrant cases not responding to topical therapy 1
• Avoid applying moisturizers or topical products immediately before phototherapy as they create a bolus effect 1
• Systemic therapies are reserved for severe or resistant cases 5

Special Considerations

• Check for possible nutrient deficiencies (thyroid function, vitamin D, zinc, ferritin) that may exacerbate seborrheic dermatitis 3
• Look for secondary bacterial infection (crusting, weeping) which requires appropriate antibiotics 1
• Watch for grouped, punched-out erosions suggesting herpes simplex superinfection, which requires acyclovir 1

Critical Pitfalls to Avoid

• Never use long-term topical corticosteroids, especially on the face, due to risk of skin atrophy, telangiectasia, and tachyphylaxis 1
• Avoid undertreatment due to fear of steroid side effects; use appropriate potency for adequate duration then discontinue 1
• Do not use mometasone or other potent corticosteroids on the face beyond 2-4 weeks due to high risk of adverse effects 1
• Distinguish seborrheic dermatitis from psoriasis (well-demarcated indurated plaques with thick silvery scale), atopic dermatitis (more intense pruritus with lichenification), and contact dermatitis (sharp demarcation corresponding to contact area) as these require different treatment approaches 1

Maintenance Strategy

• After initial clearing with ketoconazole cream, consider switching to ketoconazole shampoo for maintenance if the scalp is affected 1
• Keep nails short to minimize trauma from scratching 1
• Continue gentle skin care practices and avoid triggering factors 1