What is the treatment for seborrheic dermatitis?

Treatment of Seborrheic Dermatitis

The most effective treatment for seborrheic dermatitis combines topical antifungal agents (ketoconazole 2% cream or gel) with short-term topical corticosteroids (hydrocortisone 1% or prednicarbate 0.02%) for significant inflammation, while maintaining gentle skin care practices. 1

First-Line Treatment Approach

Topical Antifungals (Primary Therapy)

• Apply ketoconazole 2% cream twice daily for 4 weeks or until clinical clearing as the cornerstone of treatment to reduce Malassezia yeast colonization 1, 2
• Ketoconazole gel 2% once daily is equally effective and may offer better cosmetic acceptability than cream formulations 3
• For facial involvement, ketoconazole demonstrates comparable efficacy to combination therapy and maintains effectiveness for 2 weeks after treatment cessation 3

Topical Corticosteroids (Short-Term Anti-Inflammatory)

• Use hydrocortisone 1% or prednicarbate 0.02% for significant erythema and inflammation, limiting application to 2-4 weeks maximum, especially on the face 1, 4
• Hydrocortisone provides 94% symptomatic improvement compared to 81% with ketoconazole alone, though both are effective 5, 6
• Never exceed 2-4 weeks of continuous facial corticosteroid use due to high risk of skin atrophy, telangiectasia, tachyphylaxis, and acneiform eruptions 1

Essential Supportive Skin Care

Cleansing Practices

• Use mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes to preserve natural skin lipids 1
• Apply tepid (not hot) water for cleansing, as hot water worsens symptoms 1
• Pat skin dry with clean towels rather than rubbing 1

Moisturization Strategy

• Apply fragrance-free emollients containing petrolatum or mineral oil immediately after bathing to damp skin to create a lipid barrier that prevents water loss 1
• Reapply moisturizer every 3-4 hours and after each face washing 1
• Use non-greasy formulations with urea or glycerin to avoid promoting folliculitis 1

Critical Products to Avoid

• Completely avoid all alcohol-containing preparations on the face, as they significantly worsen dryness and trigger flares 1
• Avoid greasy or occlusive products that facilitate folliculitis development 1
• Avoid harsh soaps, detergents, and topical retinoids that remove natural lipids and increase irritation 1
• Avoid neomycin-containing preparations due to sensitization risk 1

Scalp-Specific Treatment

Formulation Selection

• Use shampoos, gels, solutions, or foams rather than ointments or creams for scalp involvement, as hair makes traditional formulations messy and difficult to use 1
• Apply ketoconazole 2% shampoo or selenium sulfide 1% shampoo as effective antifungal options 1
• Coal tar solution 1% can reduce inflammation and scaling when applied to the scalp not more than twice daily 1

Management of Complications

Secondary Infections

• Watch for bacterial superinfection indicated by crusting, weeping, or increased warmth—treat with oral flucloxacillin for Staphylococcus aureus 1
• Suspect herpes simplex superinfection if grouped vesicles or punched-out erosions appear—initiate oral acyclovir immediately 1

Treatment Resistance

• Consider narrowband UVB phototherapy for recalcitrant cases not responding to topical therapy after 4 weeks 1
• Avoid applying moisturizers immediately before phototherapy as they create a bolus effect 1

Maintenance Strategy

Long-Term Management

• After initial 4-week treatment with ketoconazole cream, consider switching to ketoconazole shampoo for maintenance if scalp is affected 1
• Continue gentle skin care practices and emollient use indefinitely 1
• Keep nails short to minimize trauma from scratching 1

When to Refer to Dermatology

Refer if any of the following occur: 1

• Diagnostic uncertainty or atypical presentation
• Failure to respond after 4 weeks of appropriate first-line therapy
• Recurrent severe flares despite optimal maintenance therapy
• Need for second-line treatments or consideration of phototherapy
• Suspected alternative diagnoses (psoriasis with well-demarcated indurated plaques and thick silvery scale, atopic dermatitis with intense pruritus and lichenification, contact dermatitis with sharp demarcation, or cutaneous T-cell lymphoma if refractory to standard treatment) 1

Common Pitfalls to Avoid

• Undertreatment due to excessive fear of corticosteroid side effects—use appropriate potency for adequate duration 1
• Overuse of non-sedating antihistamines, which provide no benefit in seborrheic dermatitis 1
• Prolonged continuous corticosteroid use beyond 2-4 weeks, particularly on the face 1
• Using neomycin-containing topical preparations 1