What is the recommended treatment for a patient with seborrhoeic dermatitis?

Treatment of Seborrheic Dermatitis

The most effective treatment for seborrheic dermatitis combines topical antifungal medications (ketoconazole 2%) with topical anti-inflammatory agents (low-potency corticosteroids like hydrocortisone 1%), applied according to location-specific regimens. 1

First-Line Treatment Approach

For Scalp Involvement

• Apply ketoconazole 2% shampoo as first-line therapy, which achieves an 88% response rate after initial treatment 1
• Use shampoo formulations, gels, solutions, or foams rather than creams or ointments, as hair makes traditional formulations messy and difficult to apply 1
• For significant inflammation, add clobetasol propionate 0.05% shampoo twice weekly for superior efficacy 1
• Coal tar preparations (1% strength preferred) can reduce inflammation and scaling in scalp involvement 1

For Facial and Body Involvement

• Apply ketoconazole 2% cream twice daily for four weeks or until clinical clearing 2
• For significant erythema and inflammation, add hydrocortisone 1% or prednicarbate 0.02% cream 1, 3
• Limit topical corticosteroid use to 2-4 weeks maximum, especially on the face, due to risks of skin atrophy, telangiectasia, and tachyphylaxis 1
• Avoid alcohol-containing preparations on the face as they significantly worsen dryness and trigger flares 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 water instead of hot water, as excessive heat 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 surface lipid film that prevents transepidermal water loss 1
• Use non-greasy moisturizers with urea or glycerin 1
• Reapply moisturizer every 3-4 hours and after each face washing 1

Alternative and Adjunctive Therapies

When First-Line Fails

• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) are comparable to steroids in efficacy but with fewer adverse effects, making them suitable for longer-term facial use 4
• Lithium salts are more effective than placebo (RR 8.59) and more effective than azoles for total clearance (RR 1.79) 4
• Salicylic acid 0.5-2% lotion can be applied once daily, gradually increasing to twice or three times daily if tolerated 1

For Recalcitrant Cases

• Consider narrowband UVB phototherapy for cases not responding to topical therapy after 4-6 weeks 1
• Avoid applying moisturizers immediately before phototherapy as they create a bolus effect 1
• Systemic antifungals (itraconazole 200 mg/day for first week of month, terbinafine 250 mg/day, or fluconazole 50-300 mg weekly) are reserved for severe or resistant cases 5

Monitoring for Complications

Secondary Infections

• Watch for crusting, weeping, or pustules suggesting Staphylococcus aureus superinfection—treat with oral flucloxacillin 1
• Look for grouped, punched-out erosions suggesting herpes simplex superinfection—treat immediately with oral acyclovir 1

Critical Pitfalls to Avoid

Product Selection Errors

• Never use neomycin-containing preparations due to 13-30% sensitization rates 1
• Avoid greasy or occlusive creams that facilitate folliculitis development 1
• Do not use non-sedating antihistamines as they provide no benefit in seborrheic dermatitis 1
• Avoid topical acne medications (especially retinoids) as their drying effects worsen the condition 1

Treatment Duration Mistakes

• Undertreatment due to fear of steroid side effects is a common error—use appropriate potency for adequate duration (2-4 weeks), then taper 1
• Do not confuse persistent mild itching after treatment with treatment failure, as inflammation can persist for days after yeast elimination 1

When to Refer to Dermatology

Refer if any of the following occur: 1

• Diagnostic uncertainty or atypical presentation
• Failure to respond after 4-6 weeks of appropriate first-line therapy with ketoconazole 2%
• Recurrent severe flares despite optimal maintenance therapy
• Need for second-line treatments or systemic therapy
• Suspected alternative diagnoses (psoriasis, atopic dermatitis, contact dermatitis, cutaneous T-cell lymphoma)

Maintenance Strategy

Long-Term Management

• After initial clearance with ketoconazole 2% cream, consider switching to ketoconazole shampoo for maintenance if scalp is affected 1
• Continue gentle skin care with non-soap cleansers and regular moisturization 1
• Keep nails short to minimize trauma from scratching 1
• Apply hypoallergenic sunscreen daily (at least SPF 30 with zinc oxide or titanium dioxide) 1