What are the treatment options for seborrheic dermatitis?

Treatment Options for Seborrheic Dermatitis

The most effective treatment for seborrheic dermatitis combines topical antifungal medications (primarily ketoconazole 2%) to reduce Malassezia yeast with short-term topical anti-inflammatory agents to control inflammation and itching. 1

First-Line Treatment Approach

For Scalp Involvement

• Start with ketoconazole 2% shampoo, which achieves an 88% response rate after initial treatment 1
• Apply twice weekly initially, then taper to maintenance frequency (weekly to every 3-4 weeks) once controlled 1, 2
• For significant inflammation, add clobetasol propionate 0.05% shampoo twice weekly for superior efficacy, but limit duration to avoid adverse effects 1, 2
• Alternative antifungal option: selenium sulfide 1% shampoo applied twice weekly for two weeks, then at less frequent intervals for maintenance 1, 3
• Shampoos, gels, solutions, or foams are strongly preferred over ointments and creams for scalp treatment due to ease of application through hair 1

For Facial and Body Involvement

• Apply ketoconazole 2% cream twice daily for four weeks or until clinical clearing 4
• For mild cases, gentle skin care with mild, non-soap cleansers and moisturizers may suffice 1
• Avoid all alcohol-containing preparations on the face as they significantly worsen dryness and trigger flares 1

Anti-Inflammatory Therapy (Short-Term Use Only)

When to Add Corticosteroids

• Use for significant erythema and inflammation only 1
• For facial involvement: hydrocortisone 1% or prednicarbate 0.02% cream 1
• For scalp: clobetasol propionate 0.05% shampoo 1, 2
• Critical limitation: Maximum 2-4 weeks of use, especially on the face, due to high risk of skin atrophy, telangiectasia, tachyphylaxis, and acneiform eruptions 1

Alternative Anti-Inflammatory Agents

• Topical calcineurin inhibitors (tacrolimus or pimecrolimus) are recommended for facial involvement when corticosteroids are unsuitable or for prolonged use beyond 4 weeks 1, 5
• These avoid the atrophy risk associated with corticosteroids 1

Additional Treatment Options

Keratolytic Agents

• Coal tar preparations (1% strength preferred) reduce inflammation and scaling in scalp involvement 1, 2
• Salicylic acid 0.5-2% lotion applied once daily, gradually increasing to twice or three times daily if tolerated 1
• Avoid salicylic acid 6% preparations in children under 2 years due to risk of salicylate toxicity and Reye syndrome 1

For Pruritus Management

• Topical polidocanol-containing lotions provide symptomatic relief 1
• Oral antihistamines (cetirizine, loratadina, fexofenadina) for moderate to severe itching 1
• Avoid non-sedating antihistamines as routine therapy—they provide minimal benefit 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 with tepid water only—avoid hot water which worsens symptoms 1
• Pat skin dry 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, 2
• Use non-greasy formulations with urea or glycerin 1
• Reapply every 3-4 hours and after each face washing 1

Systemic Therapy for Severe or Resistant Cases

When topical therapy fails after 4-6 weeks, consider oral antifungals 6:

• Itraconazole 200 mg/day for the first week of the month, then 200 mg/day for the first 2 days monthly for 2-11 months 6
• Terbinafine 250 mg/day either continuously for 4-6 weeks or intermittently (12 days per month) for 3 months 6
• Fluconazole 50 mg/day for 2 weeks or 200-300 mg weekly for 2-4 weeks 6
• Ketoconazole 200 mg daily for 4 weeks is associated with more relapses compared to other oral antifungals 6

Phototherapy for Refractory Cases

• Narrowband UVB phototherapy has demonstrated efficacy in open studies for recalcitrant cases not responding to topical therapy 1
• Avoid applying moisturizers or topical products immediately before phototherapy as they create a bolus effect 1

Critical Pitfalls to Avoid

Product Selection Errors

• Never use neomycin-containing preparations due to 13-30% sensitization rates 1
• Avoid greasy or occlusive products that promote folliculitis 1
• Avoid topical acne medications (especially retinoids) which worsen dryness 1

Treatment Duration Mistakes

• Undertreatment due to fear of steroid side effects leads to inadequate control—use appropriate potency for adequate duration, then taper 1
• Do not confuse persistent mild itching after treatment with treatment failure—inflammation can persist for days after yeast elimination 1

Maintenance Errors

• After initial control, continue maintenance therapy at reduced frequency rather than stopping completely 3
• For scalp involvement, consider switching to ketoconazole shampoo for long-term maintenance 1

Monitoring for Complications

Secondary Infections Requiring Specific Treatment

• Bacterial superinfection (Staphylococcus aureus): Look for increased crusting, weeping, or pustules—treat with oral flucloxacillin 1
• Herpes simplex superinfection: Watch for grouped vesicles or punched-out erosions—initiate oral acyclovir immediately 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
• Recurrent severe flares despite optimal maintenance therapy
• Need for second-line treatments or consideration of systemic therapy
• Suspected alternative diagnoses (psoriasis, atopic dermatitis, contact dermatitis, cutaneous T-cell lymphoma)