What is the recommended management for a patient with seborrheic dermatitis?

Management of Seborrheic Dermatitis

First-Line Treatment Strategy

The most effective treatment for seborrheic dermatitis combines topical antifungal medications (ketoconazole 2%) with short-term topical corticosteroids to control inflammation, supported by gentle skin care measures. 1

Topical Antifungal Therapy (Primary Treatment)

• Ketoconazole 2% cream should be applied twice daily for four weeks or until clinical clearing for facial and body seborrheic dermatitis 2
• Ketoconazole 2% shampoo is first-line for scalp involvement, with an 88% response rate after initial treatment 1
• For scalp treatment, shampoos, gels, solutions, or foams are preferred over ointments and creams due to ease of application through hair 1
• If no clinical improvement occurs after four weeks of ketoconazole treatment, the diagnosis should be reconsidered 2

Anti-Inflammatory Therapy (Adjunctive, Short-Term Only)

• Low-potency topical corticosteroids (hydrocortisone 1% or prednicarbate 0.02%) should be applied for significant erythema and inflammation, limited to 2-4 weeks maximum, especially on the face 1
• For scalp involvement with significant inflammation, clobetasol propionate 0.05% shampoo twice weekly can be added to ketoconazole for superior efficacy 1
• Avoid long-term corticosteroid use on the face due to high risk of skin atrophy, telangiectasia, tachyphylaxis, and acneiform eruptions 1

Essential Supportive Skin Care Measures

Cleansing:

• 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, as hot water worsens symptoms 1
• Pat skin dry with clean towels rather than rubbing 1

Moisturization:

• Apply fragrance-free, non-greasy moisturizers containing urea or glycerin immediately after bathing to damp skin 1
• Reapply moisturizer every 3-4 hours and after each face washing 1
• Emollients provide a surface lipid film that retards evaporative water loss 1

Critical Avoidances:

• Avoid all alcohol-containing preparations on the face, as they significantly worsen dryness and trigger flares 1
• Avoid greasy or occlusive products that promote folliculitis 1
• Avoid products containing neomycin, bacitracin, and fragrances due to sensitization risk 1
• Avoid topical acne medications (especially retinoids) that worsen dryness 1

Alternative and Second-Line Treatments

Calcineurin Inhibitors

• Topical calcineurin inhibitors are comparable to steroids in efficacy for total clearance and symptom reduction 3
• However, calcineurin inhibitors cause more adverse events than steroids in short-term use 3
• Consider for patients requiring longer-term anti-inflammatory therapy when corticosteroid risks are prohibitive 1

Lithium Salts

• Lithium salts are more effective than placebo for total clearance (RR 8.59) and more effective than azoles (RR 1.79) 3
• Comparable safety profile to placebo 3

Phototherapy

• Narrowband UVB phototherapy has shown efficacy in open studies for recalcitrant cases not responding to topical therapy 1
• Avoid applying moisturizers or topical products immediately before phototherapy due to bolus effect 1

Systemic Therapy (Severe or Refractory Cases)

• Oral fluconazole 50 mg daily for two weeks achieved clinical cure in 85% of patients with stage I-III seborrheic dermatitis 4
• Systemic therapy should be reserved for severe or treatment-resistant cases 4

Management of Complications

Secondary Bacterial Infection:

• Look for crusting, weeping, or increased erythema 1
• Treat with oral flucloxacillin for Staphylococcus aureus 1

Herpes Simplex Superinfection:

• Suspect if grouped vesicles or punched-out erosions appear 1
• Initiate oral acyclovir immediately 1

Pruritus Management:

• Oral antihistamines (cetirizine, loratadine, fexofenadina) for moderate to severe itching 1
• Avoid non-sedating antihistamines as monotherapy, as they provide minimal benefit 1
• Topical polidocanol-containing lotions can provide additional pruritus relief 1

Maintenance and Long-Term Management

• After initial clearance, consider maintenance therapy with ketoconazole shampoo for scalp involvement to prevent recurrence 1
• Gradual tapering of corticosteroids is essential to avoid rebound flares 1
• Continue supportive skin care measures indefinitely 1

When to Refer to Dermatology

Refer if:

• Diagnostic uncertainty or atypical presentation 1
• Failure to respond after 4 weeks of appropriate first-line therapy 1
• Recurrent severe flares despite optimal maintenance therapy 1
• Need for second-line treatments or consideration of phototherapy 1
• Suspected alternative diagnoses (psoriasis, atopic dermatitis, contact dermatitis, cutaneous T-cell lymphoma) 1

Common Pitfalls to Avoid

• Undertreatment due to fear of corticosteroid side effects leads to inadequate disease control 1
• Confusing persistent mild itching after treatment with treatment failure—inflammation can persist for days after yeast elimination 1
• Using corticosteroids beyond 2-4 weeks on the face risks permanent skin damage 1
• Failing to distinguish seborrheic dermatitis from psoriasis (look for well-demarcated, indurated plaques with thick silvery scale in psoriasis versus greasy, yellow scales in seborrheic dermatitis) 1