Seborrheic Dermatitis

Aka: Seborrheic Dermatitis, Seborrhea, Dandruff

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II. Epidemiology

  1. Prevalence
    1. General population: 1-3%
    2. Immunocompromised: >34%
  2. Gender
    1. More common in men
  3. Age (bimodal)
    1. Age 2 to 12 months
    2. Adolescent and young adult

III. Pathophysiology

  1. Altered skin cell functioning
    1. Results in skin inflammation with redness, itching and Scaling
  2. Associated with fungal overgrowth
    1. Normal skin colonization with the fungus Malassezia species (Malassezia furfur, Malassezia ovalis)
    2. Malassezia invade Stratum Corneum in Seborrheic Dermatitis
    3. Release Lipases that in turn result in free Fatty Acid formation
    4. Free Fatty Acids allow for increased Malassezia growth and cause the localized skin inflammation
    5. Stratum Corneum proliferates in response to inflammation and results in Scaling
    6. Stratum Corneum is also impaired as a barrier allowing for further Malassezia invasion

IV. Causes

  1. Idiopathic (most cases)

V. Risk Factors

  1. Immunocompromised state (e.g. AIDS)
  2. Increased emotional stress
  3. Cold, dry environments
  4. Sun Exposure

VI. Associated Conditions

  1. Acquired Immunodeficiency Syndrome (AIDS)
  2. Nutritional deficiency
  3. Impaired essential Fatty Acid Metabolism
  4. Neurologic conditions
    1. Parkinsonism
    2. Cerebrovascular Accident (CVA)
    3. Epilepsy

VII. Symptoms

  1. Greasy, Scaling rash on the face and scalp
  2. Pruritus

VIII. Signs

  1. See Pediatric Seborrheic Dermatitis (Cradle Cap)
  2. Characteristics
    1. Flaky, Scaling lesions with underlying erythematous patches
    2. Scaling
    3. Greasy or oily skin
  3. Distribution
    1. Common areas
      1. Scalp
      2. Nasolabial fold
    2. Facial involvement (T-distribution)
      1. Central face
      2. Beard area
      3. Eyebrows
    3. Chest involvement
      1. Under the Breast
      2. Petaloid Seborrhea (flower petal-like)
        1. Red-brown Papules with scale
        2. Papules evolve into contiguous patches
      3. Pityriasiform Seborrhea (Pityriasis Rosea-like)
        1. Generalized Macules and patches
  4. Associated skin findings
    1. Blepharitis
    2. Otitis Externa
    3. Acne Vulgaris
    4. Pityriasis Versicolor

IX. Labs: Biopsy (indicated only in unclear diagnosis)

  1. Scale crust with Neutrophils (perifollicular)
  2. Epidermal parakeratosis
  3. Plugged follicular ostia
  4. Spongiosis

X. Differential Diagnosis

  1. Acne Rosacea
  2. Atopic Dermatitis
  3. Candidiasis
  4. Contact Dermatitis
  5. Dermatophytosis
  6. Erythrasma
  7. Impetigo
  8. Langerhans Cell Histiocytosis
  9. Lichen Simplex Chronicus
  10. Nummular Eczema
  11. Pityriasis Rosea
  12. Psoriasis vulgaris
  13. Rosacea
  14. Secondary Sypilis
  15. Systemic Lupus Erythematosus
  16. Tinea Capitis or Tinea Corporis
  17. Pediculosis Ciliaris (eyelash lice)
  18. Uremic frost
    1. Occurs in end-stage renal disease with high BUN (untreated or missed Hemodialysis)
    2. Crystallized urea from sweat forms and deposits on the skin

XI. Management: Scalp

  1. Approach
    1. General
      1. Massage the Shampoo into the scalp and leave on for 5 minutes before rinsing
      2. Start with 2-3 times weekly use for several weeks until remission
      3. Maintain control with once weekly use
      4. Change to alternative product if one stops working after months of use
        1. Fungal resistance may develop to a single product
    2. Mild scalp involvement
      1. Use over-the-counter Antifungal preparations
    3. Moderate scalp involvement
      1. Start with prescription AntifungalShampoo 2-3 times weekly for several weeks until remission
      2. Maintain control with once weekly use
      3. Consider medium potency Corticosteroid intermittent, short-term use for itching, inflammation
    4. Moderate to severe scalp involvement
      1. High potency Corticosteroid (Clobetasol) twice weekly (wean as inflammation resolves)
      2. Ketaconazole 2% Shampoo twice weekly
  2. Topical Antifungals (Over-The-Counter)
    1. Coal TarShampoo twice weekly
    2. Selenium sulfide Shampoo (e.g. selsun blue moisturizing) twice weekly
    3. Tea tree oil Shampoo daily
    4. Zinc pyrithione 1% Shampoo (e.g. head and Shoulder classic) twice weekly
    5. Ketoconazole 1% (Nizoral) Shampoo
  3. Topical Antifungal Shampoos (prescription)
    1. Apply to hair for at least 5 minutes before washing out
    2. Ketoconazole 2% (Nizoral) Shampoo
      1. Start with daily use, then twice weekly
    3. Ciclopirox 1% Shampoo (Loprox)
      1. Start with daily use, then twice weekly
  4. Topical Corticosteroids
    1. Medium potency Topical Corticosteroids
      1. Betamethasone valerate 0.12% foam (Luxiq) applied daily to twice daily
      2. Fluocinolone 0.01% Shampoo (e.g. Capex) or solution (e.g. Synalar) applied daily
    2. High potency Topical Corticosteroids
      1. Clobetasol 0.05% Shampoo (Clobex) twice weekly

XII. Management: Face and Body

  1. Approach
    1. Maintenance: Topical Antifungals
      1. Topical Antifungals are first-line therapy for face and body Seborrhea
      2. As effective as Corticosteroids and safe for longterm use
    2. Inflammation or flare-ups (intermittent and short-term use)
      1. Topical Corticosteroids
      2. Calcineurin Inhibitors
  2. Topical Antifungals
    1. Ketoconazole 2% cream (Nizoral), gel (Xolegel) or foam (Extina)
      1. Twice daily for up to 8 weeks, then as needed
      2. Most reasonably priced
    2. Ciclopirox 0.77% gel or 1% cream (Ciclodan, not available in U.S.)
      1. Twice daily for up to 4 weeks
    3. Sertaconazole 2% cream (Ertaczo)
      1. Twice daily for up to 4 weeks
      2. Very expensive ($423 for 60 grams in 2014)!
  3. Topical Calcineurin Inhibitors
    1. See specific medications for precautions
      1. FDA black box warning for Lymphoma and Skin Cancer risk
    2. Tacrolimus 0.1% ointment (Protopic)
      1. Twice daily
    3. Pimecrolimus 1% cream (Elidel)
      1. Twice daily
  4. Topical Corticosteroids
    1. Medium potency Topical Corticosteroids
      1. Betamethasone valerate 0.1% cream (Beta-Val) or lotion applied once or twice daily
      2. Fluocinolone 0.01% cream, oil (Derma Smoothe) or solution (Synalar) applied once to twice daily
    2. Low potency Topical Corticosteroids
      1. Hydrocortisone 1% cream or ointment
      2. Desonide
        1. Forms: 0.05% cream, foam (Verdeso), gel (Desonate), lotion (Lokara) or ointment (Desowen)
        2. Apply once or twice daily

XIII. Preparations: Anti-inflammatory agents

  1. Decrease the skin inflammatory response (see pathophysiology above)
  2. Topical Corticosteroids
    1. High potency Topical Corticosteroids (for scalp)
      1. Clobetasol 0.05% Shampoo (Clobex) twice weekly to scalp
    2. Medium potency Topical Corticosteroids
      1. Betamethasone valerate
        1. Scalp: 0.1% lotion or 0.12% foam applied daily
        2. Face or body: 0.1% cream (Beta-Val) or lotion applied once or twice daily
      2. Fluocinolone
        1. Scalp: 0.01% Shampoo (e.g. Capex) or solution (e.g. Synalar) applied daily
        2. Face or body: 0.01% cream, oil (Derma Smoothe) or solution (Synalar) applied once to twice daily
    3. Low potency Topical Corticosteroids (for face or body)
      1. Hydrocortisone 1% cream or ointment
      2. Desonide 0.05% cream, foam (Verdeso), gel (Desonate), lotion (Lokara) or ointment (Desowen) 1-2x daily
  3. Topical Calcineurin Inhibitors (for face and body involvement)
    1. Tacrolimus 0.1% ointment (Protopic)
      1. Twice daily
    2. Pimecrolimus 1% cream (Elidel)
      1. Twice daily

XIV. Preparations: Keratolytics

  1. Remove outer layers of the hyperproliferating Stratum Corneum (see pathophysiology above)
  2. Indicated for scalp or beard area
  3. Directions
    1. Apply 2-3 times weekly
    2. Leave Shampoos applied to scalp for 5 minutes
  4. Types
    1. Salicylic acid 2-3% to remove scalp crusts
    2. Tar Shampoo
    3. Zinc pyrithione applied daily to 4 times daily

XV. Preparations: Antifungals

  1. Suppress the Malassezia fungus population (see pathophysiology above)
  2. Ketoconazole 2%
    1. Scalp: (Nizoral) Shampoo, starting with daily use, then twice weekly
    2. Face and body: Cream (Nizoral), gel (Xolegel) or foam (Extina) twice daily for 8 weeks
    3. Effective for face
    4. Of the Antifungals, most reasonably priced, and cream is best tolerated
  3. Ciclopirox
    1. Scalp: 1% Shampoo (Loprox) starting with daily use, then twice weekly
    2. Face and body: 0.77% gel or cream (Ciclodan) twice daily for up to 4 weeks
  4. Sertaconazole 2% cream (Ertaczo)
    1. Indicated for face and body involvement
    2. Twice daily for up to 4 weeks
    3. Very expensive ($423 for 60 grams in 2014)!
  5. Selenium sulfide 2.5% (Selsun)
  6. Tea Tree Oil Shampoo (5%)
    1. Antifungal activity
    2. Effective and well tolerated
    3. Satchell (2002) J Am Acad Dermatol 47:852-5 [PubMed]
  7. Other anti-fungals
    1. Fluconazole topically
    2. Oral anti-fungals (Terbinafine) have been used

XVI. Preparations: Combination therapies

  1. Triple cream compounded at pharmacy
    1. Salicylic acid 2%
    2. Hydrocortisone 0.05%
    3. Precipitated Sulfur 3%
  2. Moderate scalp involvement combination
    1. Chloroxine 2% Shampoo apply daily
    2. Flucinolone 0.01% solution apply to scalp qd to bid

XVII. References

  1. (2022) Presc Lett 29(7): 39
  2. Clark (2015) Am Fam Physician 91(3): 185-90 [PubMed]
  3. Danby (1993) J Am Acad Dermatol 29:1008-12 [PubMed]
  4. Gupta (2004) Dermatology 208:89-93 [PubMed]
  5. Scwartz (2006) Am Fam Physician 74:125-30 [PubMed]

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Related Studies

Ontology: Seborrheic dermatitis (C0036508)

Definition (CHV) a kind of skin disorder affecting the scalp, face, and trunk causing scaly, flaky, itchy, red skin
Definition (CHV) a kind of skin disorder affecting the scalp, face, and trunk causing scaly, flaky, itchy, red skin
Definition (CHV) a kind of skin disorder affecting the scalp, face, and trunk causing scaly, flaky, itchy, red skin
Definition (CHV) a kind of skin disorder affecting the scalp, face, and trunk causing scaly, flaky, itchy, red skin
Definition (CHV) a kind of skin disorder affecting the scalp, face, and trunk causing scaly, flaky, itchy, red skin
Definition (CHV) a kind of skin disorder affecting the scalp, face, and trunk causing scaly, flaky, itchy, red skin
Definition (NCI) A chronic, inflammatory skin disorder that affects the scalp, central face and skin folds; it is characterized by scaling and itching.(NICHD)
Definition (MSH) A chronic inflammatory disease of the skin with unknown etiology. It is characterized by moderate ERYTHEMA, dry, moist, or greasy (SEBACEOUS GLAND) scaling and yellow crusted patches on various areas, especially the scalp, that exfoliate as dandruff. Seborrheic dermatitis is common in children and adolescents with HIV INFECTIONS.
Concepts Disease or Syndrome (T047)
MSH D012628
ICD9 706.3, 690.10, 690.1
ICD10 L21 , L21.9
SnomedCT 156421006, 156328004, 200764003, 201241009, 50563003, 86708008
English Seborrheic dermatitis, Seborrhea, Dermatitis, Seborrheic, DERMATITIS SEBORRHEIC, Dermatitides, Seborrheic, Seborrheic Dermatitides, DERMATITIS SEBORRHOEIC, SEBORRHEA, SEBORRHOEA, SKIN SEBORRHEIC, SKIN SEBORRHOEIC, Seborrhoea NOS, Seborrheic dermatitis, unspecified, Eczema seborrheic, Dermatitis Seborrheica, Seborrheic Dermatitis, seborrheic dermatitis (diagnosis), seborrheic dermatitis, seborrhea, seborrhea (diagnosis), Dermatitis seborrheic, Dermatitis seborrhoeic, Eczema seborrhoeic, Skin seborrheic, Skin seborrhoeic, Sebrrheic dermatitis NOS, Seborrhea NOS, Dermatitis, Seborrheic [Disease/Finding], Dermatitis;seborrhoeic, Eczema;seborrhoeic, Seborheic dermatitis, unspecified, Seborrhoea (disorder), Seborrhea NOS (disorder), Seborrhoeic dermatitis (disorder), Seborrheic Eczema, Cradle Cap, Seborrheic eczema, Seborrhoea, Seborrhoeic dermatitis, Seborrhoeic eczema, SBD - Seborrheic dermatitis, SBD - Seborrhoeic dermatitis, Seborrhea (disorder), Seborrheic dermatitis (disorder), Seborrhoeic dermatitis, unspecified, dermatitis; seborrhea, eczema; seborrheic, seborrhea; dermatitis, seborrhea; eczema, seborrheic; eczema, Seborrhea, NOS, Seborrhoea, NOS, dermatitis seborrheica, Seborrheic dermatitis NOS, Dermatitis;seborrheic, Eczema;seborrheic, seborrhoea, seborrhoeic dermatitis, seborrhoeic eczema, seborrheic eczema
French SEBORRHEE, Peau séborrhéique, Dermatite séborrhéique, Dermite séborrhéique, non précisée, DERMITE SEBORRHEIQUE, PEAU SEBORRHEIQUE, Séborrhée, Dermite séborrhéique, Eczéma séborrhéique
Portuguese DERMATITE SEBORREICA, SEBORREIA, Dermatite seborreica, não especificada, Dermatite seborreica, Eczema seborreico, Dermatite seborreica NE, Pele seborreica, PELE SEBORREICA, Dermatite Seborreica, Seborreia, Dermatite seborréica
Spanish DERMATITIS SEBORREICA, SEBORREA, Piel seborreica, Eczema seborreico, Dermatitis seborreica no especificada, Dermatitis seborreica de tipo indeterminado, PIEL SEBORREICA, seborrea, SAI, seborrea, SAI (trastorno), dermatitis seborreica (trastorno), dermatitis seborreica, eccema seborreico, eccemátide seborreica, eczema seborreico, eczemátide seborreica, seborrea (trastorno), seborrea, Dermatitis seborreica, Seborrea, Dermatitis Seborreica
Dutch seborroïsch eczeem, seborroïsche huid, seborroïsche dermatitis, niet-gespecificeerd, eczeem seborroïsch, Seborroàsch eczeem, dermatitis; seborroe, eczeem; seborroïsch, seborroe; dermatitis, seborroe; eczeem, seborroïsch; eczeem, Seborroïsch eczeem, niet gespecificeerd, seborrhoea, seborroïsche dermatitis, Seborrhoea, Seborroe, Eczeem, seborroïsch, Seborroïsch eczeem
German Dermatitis seborrhoisch, Haut seborrhoisch, Ekzem seborrhoisch, seborrhoische Dermatitis, unspezifisch, seborrhoisches Ekzem, unspezifisch, seborrhoisches Ekzem, Seborrhoische Dermatitis, DERMATITIS SEBORRHOIDES, HAUT SEBORRHOISCH, SEBORRHOE, Seborrhoisches Ekzem, nicht naeher bezeichnet, Seborrhoisches Ekzem, seborrhoische Dermatitis, Dermatitis, seborrhoische, Seborrhoe
Italian Eczema seborroico, Cute seborroica, Dermatite seborroica, non specificata, Seborrea, Dermatite seborroica
Japanese 脂漏性皮膚, 脂漏性皮膚炎、詳細不明, ｼﾛｳｾｲｼｯｼﾝ, ｼﾛｳｾｲﾋﾌ, ｼﾛｳｾｲﾋﾌｴﾝｼｮｳｻｲﾌﾒｲ, ｼﾛｳ, ｼﾛｳｾｲﾋﾌｴﾝ, 脂漏症, 脂漏性皮膚炎, 脂漏性湿疹, 脂漏, 皮膚炎-脂漏性
Swedish Dermatit, seborroisk
Czech seborea, dermatitida seboroická, Seborea, Seboroická dermatitida, Seboroická dermatitis, Seboroický ekzém, Seboroická dermatitida, blíže neurčená, Seboroická kůže
Finnish Taliköhnäihottuma
Russian GIPERSTEATOZ, DERMATIT SEBOREINYI, SEBOREIA, ГИПЕРСТЕАТОЗ, ДЕРМАТИТ СЕБОРЕЙНЫЙ, СЕБОРЕЯ
Korean 상세불명의 지루피부염, 지루 피부염
Croatian DERMATITIS, SEBOROIČNI
Polish Łojotok, Zapalenie skóry łojotokowe, Wyprysk łojotokowy
Hungarian szeborheás dermatitisz, Seborrhoeás ekcéma, nem meghatározott seborrhoeás dermatitis, Seborrhoeás dermatitis, Seborrhoeás dermatitis, nem meghatározott, Seborrhoea, Dermatitis seborrhoeás, szeborheás ekcéma, Dermatitis seborrhoica, Seborrhea, seborrhoeás bőr, Bőr seborrhoeás, Seborrhoeás eczema
Norwegian Seboréisk dermatitt, Sebore, Dermatitis seborrhoica, Seboreisk dermatitt, Seboréisk eksem, Seboreisk eksem, Seboré
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Seborrheic dermatitis of scalp (C0221244)

Definition (MSH) Excessive shedding of dry scaly material from the scalp in humans.
Concepts Disease or Syndrome (T047)
MSH D063807
ICD9 690.11
ICD10 L21.0
SnomedCT 28431005, 156327009, 77592001, 200763009, 48596006, 200764003, 201177005, 312211000009106, 400201008, 156329007
English Seb dermatitis of scalp, Seborrheic dermatitis of scalp, Seborrheic dermatitis (scalp), Seborrhea capitis [dup] (disorder), seborrheic dermatitis of scalp, seborrhea capitis, seborrhea capitis (diagnosis), seborrheic dermatitis of scalp (diagnosis), scalp seborrhea, dandruff, pityriasis capitis, Seborrhoeic dermatitis capitis, Seborrheic dermatitis capitis, Scurf, Dandruff, Seborrhoeic dermatitis of scalp (disorder), Seborrhea capitis (disorder), Seborrhoea sicca, Pityriasis sicca, Seborrhea sicca, Seborrhea sicca (disorder), Dandruff [Disease/Finding], Pityriasis capitis, Seborrhea capitis, Seborrheic eczema of scalp, Seborrhoeic dermatitis of scalp, Seborrhoeic eczema of scalp, Seborrhoea capitis, Pityriasis capitis (disorder), Seborrheic dermatitis of scalp (disorder), capitis; seborrhea, seborrhea; capitis, seborrhea; sicca, sicca; seborrhea, Seborrhoea capitis (disorder)
Japanese 頭部粃糠疹, ﾄｳﾌﾞﾋｺｳｼﾝ, 頭部脂漏, ﾄｳﾌﾞｼﾛｳ, ﾄｳﾌﾞｼﾛｳｾｲﾋﾌｴﾝ, 頭部脂漏性皮膚炎
German Seborrhoea capitis, Seborrhoische Dermatitis capitis, Seborrhea capitis, Seborrhoe capitis, seborrhoische Dermatitis des Kopfes, Kopfschuppen, Schorf, Haarschuppen, Schuppen
Czech Lupy, Seboroická dermatitida na hlavě, Seborea hlavy, Seboroická dermatitida hlavy, Seborrhoea hlavy, lupy
Korean 두부지루
Hungarian Korpásodás, Seborrhoeás dermatitis a fejen, Seborrhoea capitis
Dutch seborrhoea capitis, seborroïsche dermatitis capitis, eczema seborrhoicum infantum, capitis; seborroe, seborroe; capitis, seborroe; sicca, sicca; seborroe, Seborrhoea capitis, hoofdroos
French Dermite séborrhéique du cuir chevelu, Dermite séborrhéique de la tête, Séborrhée de la tête, Séborrhée du cuir chevelu, Pellicules
Italian Seborrea del cuoio capelluto, Dermatite seborroica del cuoio capelluto, Dermatite seborroica del capo, Seborrea del capo, Desquamazione, Squama furfuracea, Forfora
Portuguese Dermatite seborreica da cabeça, Seborreia da cabeça, Caspa
Spanish Dermatitis seborreica capitis, Seborrea de la cabeza, seborrea seca, pitiriasis seca, seborrea del cuero cabelludo, pitiriasis de la cabeza, seborrea capitis, seborrea de la cabeza (trastorno), seborrea de la cabeza, caspa, seborrea seca (concepto no activo), Pityriasis capitis (trastorno), dermatitis seborreica de cuero cabelludo (trastorno), dermatitis seborreica de cuero cabelludo, Caspa, Pityriasis capitis
Russian ПЕРХОТЬ (БОЛЕЗНЬ), PERKHOT' (BOLEZN')
Derived from the NIH UMLS (Unified Medical Language System)

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