What are the treatment options for a patient with seborrheic dermatitis?

Treatment of Seborrheic Dermatitis

The most effective treatment for seborrheic dermatitis combines topical antifungal agents (ketoconazole 2%) with low-potency topical corticosteroids (hydrocortisone 1%) to simultaneously target Malassezia yeast and control inflammation. 1

First-Line Treatment Approach

Scalp Seborrheic Dermatitis

Start with ketoconazole 2% shampoo, which achieves an 88% response rate after initial treatment. 1

• Apply ketoconazole 2% shampoo to affected scalp areas, leaving on for 3-5 minutes before rinsing 2, 3
• Use twice weekly initially, then taper to once weekly for maintenance 1
• For significant inflammation, add clobetasol propionate 0.05% shampoo twice weekly for superior efficacy 1
• Alternative antifungal shampoos include selenium sulfide 1%, ciclopirox, or coal tar preparations 1, 4
• Prefer shampoos, gels, solutions, or foams over ointments and creams for scalp application, as hair makes traditional formulations messy and difficult to use 1

Facial and Body Seborrheic Dermatitis

Apply ketoconazole 2% cream twice daily for four weeks or until clinical clearing. 2

• For significant erythema and inflammation, add hydrocortisone 1% cream twice daily for 2-4 weeks maximum 1, 5
• Avoid prolonged corticosteroid use on the face beyond 2-4 weeks due to high risk of skin atrophy, telangiectasia, and tachyphylaxis 1
• Alternative topical antifungals include ciclopirox, clotrimazole, or miconazole 6
• For maintenance, consider topical calcineurin inhibitors (tacrolimus or pimecrolimus) as steroid-sparing agents 6, 7

Essential Supportive Skin Care

Avoid all alcohol-containing preparations on the face, as they significantly worsen dryness and trigger flares. 1

• Use mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes to preserve natural skin lipids 1
• Apply fragrance-free moisturizers containing petrolatum or mineral oil immediately after bathing to damp skin 1
• Use tepid water instead of hot water for cleansing 1
• Pat skin dry with clean towels rather than rubbing 1
• Avoid products containing neomycin, bacitracin, or fragrances due to high sensitization rates 1

Treatment Duration and Monitoring

If no clinical improvement occurs after four weeks of appropriate first-line therapy, refer to dermatology. 1

• Candidal infections and tinea require two weeks of treatment to reduce recurrence 2
• Seborrheic dermatitis typically requires four weeks of ketoconazole 2% cream applied twice daily 2
• Watch for secondary bacterial infection (crusting, weeping) requiring flucloxacillin 1
• Suspect herpes simplex superinfection if grouped vesicles or punched-out erosions appear, requiring immediate oral acyclovir 1

Second-Line Options for Resistant Cases

For cases not responding to topical therapy after 4-6 weeks, consider narrowband UVB phototherapy or systemic antifungals. 1, 6

• Narrowband UVB phototherapy (312 nm) has demonstrated efficacy in open studies for recalcitrant seborrheic dermatitis 1
• Avoid applying moisturizers or topical products immediately before phototherapy, as they create a bolus effect 1
• Systemic antifungals (itraconazole or terbinafine) are reserved for severe or widespread lesions refractory to topical treatment 4, 6

Critical Pitfalls to Avoid

Undertreatment due to fear of corticosteroid side effects leads to poor disease control—use appropriate potency for adequate duration, then taper. 1

• Do not use non-sedating antihistamines, as they provide no benefit in seborrheic dermatitis 1
• Do not confuse persistent mild itching after treatment with treatment failure, as inflammation can persist for days after yeast elimination 1
• Avoid greasy or occlusive products that can promote folliculitis development 1
• Do not use very potent corticosteroids on the face due to rapid development of adverse effects 1

Differential Diagnosis Considerations

Distinguish seborrheic dermatitis from psoriasis by looking for well-demarcated, indurated plaques with thick silvery scale rather than greasy, yellow scales. 1

• Psoriatic plaques are more sharply defined and thicker than seborrheic dermatitis lesions 1
• Atopic dermatitis presents with more intense pruritus and lichenification, often with flexural involvement 1
• Contact dermatitis shows sharp demarcation corresponding to contact area 1
• Consider cutaneous T-cell lymphoma if refractory to standard treatment 1

Maintenance Strategy

After achieving clearance, taper ketoconazole to once or twice weekly application to prevent relapse. 1

• Keep nails short to minimize trauma from scratching 1
• Continue gentle skin care with non-soap cleansers and regular moisturization 1
• Monitor for flare-ups requiring reinitiation of twice-daily antifungal therapy 1