seborrheic%20dermatitis
SEBORRHEIC DERMATITIS
Seborrheic dermatitis is a chronic inflammatory skin disorder characterized by fine scaling and erythema mostly confined to areas where sebaceous glands are prominent.
Pityrosporum ovale infection is common in seborrheic dermatitis.
The characteristic pattern is based on age group.
In infants it appears as cradle cap. It is a diffuse or focal scaling and crusting on the vertex of the scalp that sometimes accompanied by inflammation.
In young children, there is Tinea amiantacea which is one or several patches of dense, plate-like scales, 2-10 cm in size that appear anywhere on the scalp.
While adolescents have dandruff which are fine, dry, white, non-inflammatory scalp scaling with minor itching.

Pharmacotherapy

Antibiotics1

  • Antistaphylococcal penicillins (oral) should be used in cases of secondary bacterial infection
  • Infection should be controlled before applying topical corticosteroids

Metronidazole

  • Topical form may be used for the treatment of facial SD
  • Has comparable therapeutic effects w/ topical Ketoconazole

Antifungals (Oral)1

  • Indicated for non-scalp & widespread/refractory SD

Itraconazole

  • May be used for patients w/ persistent SD resistant to topical therapies
  • A 7-day treatment course resulted in substantial improvement in approximately 75% of patients
  • Also has anti-inflammatory properties

Terbinafine

  • A 4-week treatment regimen led to improvements in erythema, scaling & pruritus
  • Significantly more effective than placebo in reducing dermatitis severity in non-exposed skin areas

Antifungals (Topical)

  • Used for both scalp, non-scalp, & refractory seborrheic dermatitis

Azole Derivatives

  • Eg Ketoconazole, Miconazole, Sertaconazole, Ciclopiroxolamine
  • Act by reducing fungal ergosterol synthesis by inhibiting the fungal cytochrome P450 enzymes
  • Decrease colonization by lipophilic yeast
  • Ketoconazole is as effective as corticosteroid & is a good treatment alternative in infants
    • Effectively reduces erythema, pruritus & scaling in mild to severe SD of the scalp & body
    • Prolonged use is associated with adverse effects (eg decreased biosynthesis of adrenal & gonadal steroid hormones)
    • May also be considered an alternative to keratolytic when applied to affected areas for 5-10 minutes before rinsing

Ciclopirox (Ciclopiroxolamine)

  • Has a wide spectrum of antifungal activity as well as some anti-inflammatory & antibacterial activity
  • Effective against even the most difficult & diffuse cases

Terbinafine

  • A synthetic allylamine that inhibits fungal enzyme squalene epoxidase, thereby interfering w/ ergosterol biosynthesis
  • Effective in reducing scalp, face & body seborrhea

Calcineurin Inhibitors (Topical)

  • Eg Pimecrolimus 1% cream, Tacrolimus 0.1% ointment
  • Inhibit inflammatory cytokine transcription in activated T cells & other inflammatory cells through inhibition of calcineurin
  • Have fungicidal & anti-inflammatory properties without causing cutaneous atrophy
  • Good therapeutic options when the face & other parts of the body other than the scalp are affected
  • Alternative treatment for mild to severe refractory SD
  • At least 1 week of daily use is necessary before benefits become apparent
  • Not recommended in patients <2 years of age; long-term use should be avoided & limited to involved areas only

Corticosteroid (Topical)

  • Eg Alclometasone, Betamethasone valerate, Desonide, Fluocinolone, Hydrocortisone
  • Acts by reducing the concentration of peripheral leukocytes in the inflammatory site & redistributing them to lymphoid tissue
  • It suppresses the effects of inflammatory cytokines, chemokines & other lipid & glycolipid mediators of inflammation
  • Used primarily for their anti-inflammatory activity, but also have antimitotic effects on the epidermis
  • Soln & oint are useful for scalp lesions, while lotions & creams are appropriate for other parts of the body
  • Mildly potent corticosteroids are preferred to minimize the risk of toxicity eg skin atrophy, telangiectasia
  • Very potent corticosteroids are not recommended for >2 wk & must be discontinued as soon as treatment response is noted
  • In cases of combination treatment failure in patients w/ refractory or widespread seborrheic dermatitis, short-term use of a more potent corticosteroid in a pulse fashion may be effective

Emollients

  • Eg Bisabolol, Glycyrrhetic acid, Piroctone olamine, Shea butter, Tea tree oil (Melaleuca alternifolia), Vitis vinifera
  • May be used for the relief of symptoms especially in patients w/ mild scalp & non-scalp SD
    • Reduces scaling in infants w/ cradle cap
  • Bisabolol, Glycyrrhetic acid, & Piroctone olamine has both anti-inflammatory & antifungal properties

Keratolytic Agents

  • Anti-dandruff shampoo containing keratolytic agent should be used at least every other day

Coal Tar

  • Useful in treating dense seborrhea of the scalp, face & body
  • Phenolic constituents of coal tar account for its antipruritic effect

Lipohydroxy acid

  • May be used for treatment of SD of the scalp
  • Has both antifungal & exfoliating properties
  • Studies have shown that Lipohydroxy acid is comparable to the effect of Ciclopiroxolamine on SD patients

Propylene glycol

  • May be used for mild to severe SD of the scalp
  • Studies showed improvement of erythema & desquamation w/ daily application after 4 wk
  • Possesses humectant properties, & moisturizes & protects the skin

Salicylic acid

  • Effective in removing dense scales
  • Exact mechanism is unknown, although salicylic acid may solubilize cell surface proteins that keep the stratum corneum intact resulting in desquamation of keratotic debris

Selenium sulfide

  • May be used in treating seborrhea of the scalp, face & body
  • Has both keratolytic & antifungal activity

Sulfur

  • Exerts keratolytic action through its ability to form hydrogen sulfide on contact w/ keratinocytes

Zinc Pyrithione

  • Exerts nonspecific keratolytic activity & decreases colonization by lipophilic yeast

Retinoids1

  • May be used as an alternative therapy in refractory disease; lowest dose recommended
  • Reduce sebaceous gland activity

Other Therapies

  • Other non-steroidal combination therapies1 containing antioxidants (ie Tocopheryl acetate, Telmesteine) may help relieve symptoms

1Various products are available. Please see prescribing information for specific formulations in the latest MIMS.

Non-Pharmacological Therapy

Scalp & skin care1

  • Frequent cleansing of the affected areas with soap removes oils & improves seborrhea
  • Moisturizing emollients should be used after washing the skin
  • Removing dense scales on the scalp:
    • Apply warm mineral oil or olive oil to the scalp & rinse several hours later with a detergent (eg dishwashing liquid) or a tar shampoo
    • Leave a coal tar-keratolytic combination or phenol-saline solution overnight & shampoo off in the morning
  • Seborrheic blepharitis may respond to gentle cleaning of eyelashes with baby shampoo & cotton applicators
  • Minimize hair spray, gel & sunlight exposure

Wet compresses

  • Should be applied to moist or fissured lesions before applying topical corticosteroids

Phototherapy

  • May be used as an alternative treatment in patients with widespread or refractory seborrheic dermatitis
  • UVA & UVB inhibit the growth of P ovale, & many patients experience improvement in seborrhea during summer

1Various products are available. Please see prescribing information for specific formulations in the latest MIMS.

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