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
- 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 have 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 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.