What is the treatment for scalp seborrheic dermatitis?

Treatment for Scalp Seborrheic Dermatitis

For scalp seborrheic dermatitis, start with ketoconazole 2% shampoo twice weekly for 2-4 weeks, then transition to once-weekly maintenance therapy to prevent relapse. 1, 2, 3

First-Line Treatment: Antifungal Shampoos

Ketoconazole 2% shampoo is the gold standard for scalp seborrheic dermatitis, demonstrating an 88% excellent response rate when used twice weekly for 2-4 weeks. 3 The FDA-approved regimen for ketoconazole 2% cream (which can guide shampoo use) recommends twice-daily application for four weeks or until clinical clearing. 2

Maintenance Therapy to Prevent Relapse

• Once initial control is achieved, continue ketoconazole shampoo once weekly for long-term prophylaxis. 4, 3
• Weekly maintenance reduces relapse rates from 47% (placebo) to 19% (active treatment), making it essential for sustained disease control. 3
• This long-term antifungal approach is preferred over repeated corticosteroid courses. 4

Alternative Antifungal Shampoos

• Selenium sulfide 1% shampoo, pyrithione zinc shampoo, or coal tar shampoos are effective alternatives if ketoconazole is unavailable or not tolerated. 1, 5, 6
• These over-the-counter options should be the initial approach before escalating to prescription agents. 4

Second-Line Treatment: Topical Corticosteroids

For cases not responding to antifungal shampoos alone, add short-term topical corticosteroids (2-4 weeks maximum). 1, 5

• Use clobetasol propionate 0.05% shampoo or solution formulations for the scalp, as shampoos, gels, solutions, and foams are superior to creams and ointments in hair-bearing areas. 1, 7
• Limit corticosteroid use to 2-4 weeks only to avoid skin atrophy, telangiectasia, and tachyphylaxis. 1, 7
• Never use corticosteroids as monotherapy or for long-term maintenance—they are adjuncts only during acute flares. 1

Managing Thick, Adherent Scale

For dense, diffuse scalp scale, use keratolytic agents before antifungal therapy. 8, 6

• Apply mineral oil or keratolytic shampoos to loosen thick scale, allowing better penetration of antifungal agents. 8
• Coal tar preparations (1% strength preferred) reduce inflammation and scaling effectively. 1, 7

Essential Supportive Care Measures

• Use mild, pH-neutral (pH 5) non-soap cleansers with tepid water only—hot water and harsh soaps strip natural lipids and worsen the condition. 7
• Apply fragrance-free, non-greasy moisturizers immediately after bathing to damp skin to create a lipid barrier preventing water loss. 1, 7
• Avoid all alcohol-containing hair products, as they significantly worsen dryness and trigger flares. 7

Monitoring for Complications

• Watch for secondary bacterial infection (crusting, weeping, honey-colored discharge) requiring oral flucloxacillin for Staphylococcus aureus. 1, 7
• Look for grouped, punched-out erosions suggesting herpes simplex superinfection, which requires immediate oral acyclovir. 7
• Check for contact dermatitis from topical preparations, particularly neomycin (causes reactions in 5-15% of patients). 1, 5

When to Refer to Dermatology

Refer if any of the following occur: 7

• 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 systemic treatments

Common Pitfalls to Avoid

• Do not use topical corticosteroids continuously or as monotherapy—this leads to tachyphylaxis, skin atrophy, and rebound flares. 1, 7
• Do not discontinue antifungal therapy once symptoms clear—transition to weekly maintenance to prevent the 47% relapse rate seen without prophylaxis. 3
• Do not use non-sedating antihistamines—they provide no benefit in seborrheic dermatitis. 7
• Do not apply greasy or occlusive products to the scalp—these promote folliculitis. 7