Seborrheic%20dermatitis Treatment

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 (Oral)

• Eg Prednisone
• May be considered as a systemic treatment option for recalcitrant moderate to severe SD patients unresponsive or with contraindications to oral antifungals
• Prolonged/frequent use should be avoided; gradual tapering is recommended

Corticosteroid (Topical)

• Eg Alclometasone, Betamethasone valerate, Clobetasol propionate, 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 

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

Nonsteroidal Anti-inflammatory with Antifungal Properties (AIAFp)¹

• Alglycera, Bisabolol, Glycyrrhetic acid, Piroctone olamine, and Telmesteine have both anti-inflammatory and antifungal properties
• Piroctone olamine/Bisabolol/Glycyrrhetic acid/Lactoferrin shampoo is an example of AIAFp used in scalp SD
• AIAFp used for non-scalp SD include Piroctone olamine/Alglycera/Bisabolol cream, and Piroctone olamine/Bisabolol/Alglycera/Telmesteine cream

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 the latest MIMS for specific formulations and prescribing information.

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 the latest MIMS for specific formulations and prescribing information.