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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