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.

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 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 & 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.