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 (multimodal)
    1. Age 2 to 12 months (Cradle Cap, self-limited and resolves)
    2. Adolescent and young adult
    3. Older adult

III. Pathophysiology

  1. Primary Factors
    1. Sebum overproduction by Sebaceous Glands (Seborrhea)
    2. Malassezia yeast overgrowth (see below)
    3. Disrupted epidermal skin barrier
    4. Dysregulated inflammatory response
  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
  3. Dysregulated inflammatory response
    1. Inflammatory response with Cytokine release and T Cell activation
    2. Results in skin inflammation with redness, itching and Scaling

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 (up to 59%)
    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
  5. Other findings in Skin of Color
    1. Hypopigmentation patches in eyebrows and nasolabial fold
    2. Petaloid Seborrhea
      1. Well-demarcated scaly Plaques affecting the hairline and face

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. Common Scalp conditions
    1. See Scalp Dermatitis
    2. Tinea Capitis
    3. Eczema (Atopic Dermatitis)
      1. Dry scalp flaking (contrast with oily Seborrhea)
    4. Contact Dermatitis
      1. Contact reaction to hair dyes or Shampoos also affects the top of ears and posterior neck
    5. Psoriasis
      1. Thick, well-demarcated erythematous Plaques with overlying adherent scale
  2. Nasolabial fold
    1. Inverse Psoriasis (smooth Plaques without scale)
    2. Erythrasma
    3. Impetigo
    4. Intertrigo causes
      1. Irritant dermatitis
      2. Allergic Contact Dermatitis
      3. Candidiasis or Dermatophytosis
  3. External Ear
    1. See Ear Canal Dermatitis
    2. Psoriasis
    3. Otitis Externa
    4. Allergic Contact Dermatitis
  4. Face
    1. Acne Rosacea
      1. Inflammatory acne without scale, and central Flushing, Telangiectasia
    2. Other uncommon causes
      1. Systemic Lupus Erythematosus
      2. Secondary Sypilis
      3. Pediculosis Ciliaris (eyelash lice)
      4. Langerhans Cell Histiocytosis
      5. Lichen Simplex Chronicus
      6. 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 daily use for several weeks until remission
      3. Maintain control after remission with use 2 times weekly
      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. See application protocol above
      1. Applied for 5 minutes daily until remission, then twice weekly
    2. Indications
      1. First-line therapy in Mild Seborrheic Dermatitis
    3. First-Line Agents
      1. Selenium sulfide 1% Shampoo (e.g. selsun blue moisturizing)
      2. Ketoconazole 1% (Nizoral) Shampoo
      3. Zinc pyrithione 1% Shampoo (e.g. head and Shoulder classic)
        1. Leave-in preparation that may be more effective if infrequent hair washing (e.g. <=twice weekly)
    4. Other alternative agents (esp. thick, adherent scalp Scaling)
      1. Coal TarShampoo (rare use, but likely effective)
      2. Tea tree oil 5% Shampoo daily
  3. Topical Antifungal Shampoos (prescription)
    1. See application protocol above
      1. Applied for 5 minutes daily until remission, then twice weekly
    2. Ketoconazole 2% (Nizoral) Shampoo
    3. Ciclopirox 1% Shampoo (Loprox)
    4. Selenium Sulfide 2.25% Shampoo
  4. Topical Corticosteroids
    1. Indications
      1. Refractory Seborrheic Dermatitis to other topicals (see above)
    2. Protocol
      1. Limit to 2 weeks of frequent use (3-7x/week), then taper to occasional use
      2. Do NOT use high potency Corticosteroids on the face (scalp only)
    3. Medium potency Topical Corticosteroids (mild to moderate refractory cases)
      1. Fluocinolone 0.01% Shampoo (e.g. Capex) or solution (e.g. Synalar) applied daily
      2. Betamethasone valerate 0.12% foam (Luxiq) applied daily to twice daily
    4. High potency Topical Corticosteroids (moderate to severe refractory cases, use <2 weeks)
      1. Clobetasol Propionate 0.05% foam or Shampoo (Clobex)
      2. Mometasone furoate 0.1% solution
      3. Fluocinonide 0.05% solution
      4. Betamethasone Dipropionate lotion or foam
  5. Other agents in Seborrheic Dermatitis refractory to all other topical agents
    1. Oral Antifungals
    2. Roflumilast 0.3$ foam
      1. Expensive, Phosphodiesterase-4 Inhibitor applied daily until remission

XII. Management: Face, Ear and Body

  1. Approach
    1. Gentle skin care
      1. Nonsoap cleansers
      2. Oil-free noncomedogenic, hypoallergenic skin Emollients
    2. 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
    3. Inflammation or flare-ups (intermittent and short-term use, ideally for <10-14 days)
      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. Miconazole 2% Cream
    4. Sertaconazole 2% cream (Ertaczo)
      1. Twice daily for up to 4 weeks
      2. Very expensive ($423 for 60 grams in 2014)!
  3. Topical Corticosteroids (short-term use for flares)
    1. Low potency Topical Corticosteroids (for facial use)
      1. Hydrocortisone 1 to 2.5% cream or ointment
      2. Desonide
        1. Forms: 0.05% cream, foam (Verdeso), gel (Desonate), lotion (Lokara) or ointment (Desowen)
        2. Apply once or twice daily
    2. Medium potency Topical Corticosteroids (limit to use on body; avoid use on face)
      1. Betamethasone valerate 0.1% cream (Beta-Val) or lotion applied once or twice daily
      2. Fluocinolone 0.01% cream, oil (Derma Smoothe) or solution (Synalar) applied once to twice daily
      3. Mometasone 0.1% cream or ointment
      4. Triamcinolone 0.1% cream or ointment
  4. Topical Calcineurin Inhibitors
    1. Indications
      1. Seborrheic Dermatitis refractory to topical agents above, or if prolonged Corticosteroid use needed
    2. See specific medications for precautions
      1. FDA black box warning for Lymphoma and Skin Cancer risk
    3. Tacrolimus 0.1% ointment (Protopic)
      1. Twice daily until remission, then maintenance with twice weekly application
    4. Pimecrolimus 1% cream (Elidel)
      1. Twice daily until remission, then maintenance with twice weekly application
  5. Other agents in Seborrheic Dermatitis refractory to all other topical agents
    1. Metronidazole 0.75% gel
    2. Sodium sulfacetamide
    3. Azelaic Acid 15%
    4. Oral Isotretinoin at low dose
    5. Roflumilast 0.3$ foam
      1. Expensive, Phosphodiesterase-4 Inhibitor applied daily until remission
    6. Oral Antifungals
      1. Fluconazole 50 mg orally daily for 2 weeks OR
      2. Fluconazole 200 mg orally weekly for 2 to 4 weeks

XIII. Medications: 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. Medications: 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. Medications: 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. Medications: 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 daily to twice daily

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. LeFevre (2025) Am Fam Physician 112(2):166-73 [PubMed]
  6. Scwartz (2006) Am Fam Physician 74:125-30 [PubMed]

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