What are the treatment and management instructions for a patient with seborrhoeic dermatitis?

Management Instructions for Seborrheic Dermatitis

For seborrheic dermatitis, apply ketoconazole 2% cream twice daily to affected areas for four weeks, combined with gentle skin care using pH-neutral cleansers and daily moisturization, while strictly avoiding alcohol-containing products on the face. 1, 2

Primary Treatment Approach

Topical Antifungal Therapy

• Apply ketoconazole 2% cream to affected areas twice daily for four weeks or until clinical clearing. 1
• For scalp involvement, ketoconazole 2% shampoo used twice weekly for 2-4 weeks achieves an 88% excellent response rate. 3
• After initial clearing, maintain remission with ketoconazole 2% shampoo once weekly to prevent relapse (reduces recurrence from 47% to 19% compared to no maintenance). 3

Anti-Inflammatory Management

• For significant erythema and inflammation, apply hydrocortisone 1% cream or prednicarbate 0.02% cream for limited periods only (maximum 2-4 weeks, especially on the face) due to risks of skin atrophy, telangiectasia, and tachyphylaxis. 2
• Never use topical corticosteroids continuously on the face beyond 2-4 weeks. 2

Essential Daily Skin Care Regimen

Cleansing Protocol

• Use mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes with tepid water only—never hot water. 2
• Pat skin dry with clean, smooth towels rather than rubbing. 2
• Avoid harsh soaps and detergents as they remove natural lipids from the skin surface, worsening dryness. 2

Moisturization Strategy

• Apply hypoallergenic, non-greasy moisturizing creams or emollients containing petrolatum or mineral oil immediately after bathing to damp skin once daily. 2
• Reapply moisturizer every 3-4 hours and after each face washing. 2
• Use the two-fingertip-unit method for adequate coverage. 2

Critical Products and Practices to Avoid

Prohibited Products

• Completely avoid all alcohol-containing preparations on the face—they significantly worsen dryness and trigger flares. 2
• Avoid greasy or occlusive creams as they facilitate folliculitis development. 2
• Avoid topical acne medications (especially retinoids) due to their drying effects that worsen the condition. 2
• Avoid products containing neomycin, bacitracin, or fragrances due to high sensitization rates (13-30% with neomycin). 2

Prohibited Practices

• Never use hot water—use tepid water only. 2
• Avoid rubbing skin dry after bathing. 2
• Avoid skin manipulation as it increases infection risk. 2
• Avoid hot blow-drying of hair. 4

Sun Protection Requirements

• Apply hypoallergenic sunscreen daily (minimum SPF 30, UVA/UVB protection) containing zinc oxide or titanium dioxide to all exposed skin areas regardless of season. 2
• Wear protective clothing and hats for additional sun protection. 2
• Stay out of direct sun whenever possible. 4

Scalp-Specific Instructions

• For scalp involvement, use shampoos, gels, solutions, or foams rather than ointments and creams, as hair makes traditional formulations messy and difficult to use. 2
• Apply ketoconazole 2% shampoo to wet scalp, lather, leave on for 3-5 minutes, then rinse thoroughly. 3
• Coal tar solution 1% can be used as an alternative to reduce inflammation and scaling. 2

Monitoring for Complications

• Watch for secondary bacterial infection (crusting, weeping) requiring oral flucloxacillin for Staphylococcus aureus. 2
• Look for grouped vesicles or punched-out erosions suggesting herpes simplex superinfection, which requires immediate oral acyclovir. 2
• Keep nails short to minimize trauma from scratching. 2

When to Seek Dermatology Referral

• Diagnostic uncertainty or atypical presentation. 2
• Failure to respond after 4 weeks of appropriate ketoconazole 2% treatment. 2
• Recurrent severe flares despite optimal maintenance therapy. 2
• Need for second-line treatments or suspected alternative diagnoses (psoriasis, atopic dermatitis, contact dermatitis). 2

Common Pitfalls to Avoid

• Undertreatment due to fear of corticosteroid side effects—use appropriate potency for adequate duration, then taper. 2
• Confusing persistent mild itching after treatment with treatment failure—mild burning or itching from inflammation can persist for days after yeast is eliminated and does not indicate need for re-treatment. 2
• Overuse of non-sedating antihistamines, which provide no benefit in seborrheic dermatitis. 2