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.

Seborrheic%20dermatitis Treatment

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 with topical Ketoconazole

Antifungals (Oral)1

  • Eg Fluconazole, Itraconazole, Ketoconazole, Terbinafine 
  • Indicated for non-scalp and widespread/refractory SD

Itraconazole

  • May be used for patients with 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 and pruritus
  • Significantly more effective than placebo in reducing dermatitis severity in non-exposed skin areas

Antifungals (Topical)

  • Reduce Malassezia population 
  • Used for both scalp, non-scalp, and refractory seborrheic dermatitis

Azole Derivatives

  • Eg Ketoconazole, Miconazole, Sertaconazole
  • Act by reducing fungal ergosterol synthesis by inhibiting the fungal cytochrome P450 enzymes
  • Decrease colonization by lipophilic yeast
  • Ketoconazole is as effective as corticosteroid and is a good treatment alternative in infants
    • Effectively reduces erythema, pruritus and scaling in mild to severe SD of the scalp and body
    • Prolonged use is associated with adverse effects (eg decreased biosynthesis of adrenal and 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 and antibacterial activity
  • Effective against even the most difficult and diffuse cases

Terbinafine

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

Calcineurin Inhibitors (Topical)

  • Eg Pimecrolimus 1% cream, Tacrolimus 0.1% ointment
  • Inhibit inflammatory cytokine transcription in activated T cells and other inflammatory cells through inhibition of calcineurin
  • Have fungicidal and anti-inflammatory properties without causing cutaneous atrophy
  • Good therapeutic options when the face and 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 and 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 and redistributing them to lymphoid tissue
  • It suppresses the effects of inflammatory cytokines, chemokines and other lipid and glycolipid mediators of inflammation
  • Used primarily for their anti-inflammatory activity, but also have antimitotic effects on the epidermis
  • Solution and ointment are useful for scalp lesions, while lotions and 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 weeks and must be discontinued as soon as treatment response is noted
  • In cases of combination treatment failure in patients with 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 with mild scalp and non-scalp SD
    • Reduces scaling in infants with cradle cap
  • Bisabolol, Glycyrrhetic acid, and Piroctone olamine have both anti-inflammatory and antifungal properties

Keratolytic Agents

  • Used to prevent scaling or crust formation and help improve the penetration of other topical treatment 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 and 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 and 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 and desquamation with daily application after 4 weeks
  • Possesses humectant properties, and moisturizes and 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 and body
  • Has both keratolytic and antifungal activity

Sulfur

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

Zinc pyrithione

  • Exerts nonspecific keratolytic activity and decreases colonization by lipophilic yeast
  • Possess antibacterial and antifungal activity
  • May be used for treatment of mild SD of the scalp

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 and Skin Care1

  • Frequent cleansing of the affected areas with soap removes oils and 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 and 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 and shampoo off in the morning
  • Seborrheic blepharitis may respond to gentle cleaning of eyelashes with baby shampoo and cotton applicators
  • Minimize hair spray, gel and sunlight exposure

Wet Compress

  • 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 and UVB inhibit the growth of Malassezia, and 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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