Seborrheic Dermatitis Treatment

Primary Care Visit Report   

A 42-year-old female with past medical history of  psoriasis   presented with a rash on her face. She reported having similar outbreaks in the past, and they would resolve with application of tea tree oil. The present rash started about a week prior to visit, on the left nasal and cheek area. It was itchy, and she treated it by applying apple cider compresses, drinking coconut oil, and taking vitamins. The initial rash on the left side improved, but 3 days prior to visit a similar rash appeared on her right cheek, nasal area, and right chin, and progressively worsened since then. She tried one application of hydrocortisone valerate on the  rash   about 5 days prior to visit, and it did not help. 

Seborrheic


 Vitals were normal. On exam, the right lateral alar crease had an erythematous scabbing rash, and the right nasolabial fold had a 1 cm × 3 cm erythematous papular rash. Her right lateral chin had a honey-crusted 1 cm × 1 cm erythematous papular rash, and her left alar crease featured a minimal erythematous  papular rash  . 

 This was treated as seborrheic dermatitis with overlaying impetigo, and the patient was prescribed hydrocortisone butyrate (Class V steroid) cream 0.1 % twice daily for 10 days for the seborrheic dermatitis and oral cephalexin 500 mg twice daily for 10 days plus mupirocin ointment 2 % three times daily for 10 days for the impetiginization.  

    Discussion from Dermatology Clinic 

     Differential Dx   

 Seborrheic dermatitis  

 Mild  psoriasis    

 Impetigo  

Dermatophyte  fungal infection  , e.g., tinea capitis, tinea faciei, tinea corporis

 Subacute lupus erythematosus  

 Candidiasis       

Favored Dx   

Given the distribution and appearance of this rash, the favored diagnosis is seborrheic dermatitis, with one impetiginized area. However, seborrheic dermatitis and mild  psoriasis   are sometimes clinically indistinguishable when present on the face or  scalp  , and diagnosis is often times just a matter of how much scale is present, and how thick the plaques are. The term  sebopsoriasis   is sometimes used in those cases. Both facial seborrheic dermatitis and psoriasis can be successfully controlled with mild topical steroids, but may differ in their long-term management, as described below.  

Overview   

Seborrheic dermatitis is a common, chronic cutaneous condition involving areas of the body with active sebaceous glands, such as the scalp, face, chest, and back. Its pathogenesis is controversial [ 1 ], and it has been associated with presence of yeast of the genus   Malassezia   . Many factors contribute to its pathogenesis.  Malassezia  metabolites, such as oleic acid, compromise the permeability of the skin barrier, becoming more susceptible to irritants and triggering an infl amma-tory response [ 1 ]. Seborrheic dermatitis, also sometimes called  seborrheic eczema  , may be classifi ed as a type of dermatitis, a  fungal infection  , or an infl ammatory process similar to  psoriasis .  

 Seborrheic dermatitis occurs in 1–3 % of immunocompetent adults [ 1 ]. It also occurs more commonly in immunocompromised populations, such as patients who are HIV positive or have AIDS (34–83 % incidence), those with chronic alcoholic pancreatitis, hepatitis C virus, cardiac transplants, or various cancers, and patients with neurological conditions, such as Parkinson’s [ 1 – 3 ]. 

The onset of seborrheic dermatitis is commonly during infancy (when it is known as  cradle cap  ), puberty, young adulthood, and past the age of 50. It is more prevalent in men than women [ 2 ,  3 ].  

Presentation   

Seborrheic dermatitis is characterized by red,  flaking   thin plaques. Presentation var-ies greatly in the degree of erythema,  flaking, pruritus, and greasy appearance of lesions [ 2 ]. It tends to be exacerbated by cold, dry weather and may improve during summer months. Lesions may appear on the  scalp  , forehead, eyebrows, nasolabial folds, folds behind the external ears, ear canals, and suprasternal area. Presentation on the scalp is usually restricted to scaling and fl aking. The retroauricular crease can have crusts and fissures.  

Workup   

The cause of seborrheic dermatitis is controversial, and many factors contribute to its development [ 2 ]. Accordingly lab workups may not necessarily be helpful. For example, a fungal culture may reveal the presence of  Malassezia    yeast  ; however, the yeast is present in most people regardless of whether they have seborrheic dermati-tis. A bacterial culture would rule out impetigo. 

Histologically, seborrheic dermatitis has a characteristic spongiosis, which is intercellular edema in the epidermis, that renders it distinct from  psoriasis  .  

Treatment   

Several different medications may be used to treat seborrheic dermatitis as there are many factors that contribute to its pathogenesis. Topical anti-infl ammatory, such as  corticosteroids   and calcineurin inhibitors,  antifungal  , and keratolytic agents may be used. Topical azole  antifungals   are most effective in achieving long-term clearance, and topical steroids are most effective at reducing erythema, scaling and pruritus without unwanted side effects [ 4 ]. 

Combination therapy   may provide the best approach to addressing multiple symp-toms. Our practice prescribes ketoconazole 2 % cream and desonide 0.05 % cream (Class VI) twice daily for 2 weeks to treat seborrheic dermatitis on the face (applied in any order). Combination therapy alternating ketoconazole 2 % shampoo and clobeta-sol propionate 0.05 % shampoo each twice weekly for 4 weeks demonstrates higher effi cacy than either shampoo alone in treating seborrheic dermatitis of the  scalp   [ 5 ].  

Follow-Up   

Seborrheic dermatitis tends to be a chronic and recurring condition. Treatment alle-viates symptoms but does not provide a cure, thus long-term maintenance plans are necessary.  Maintenance therapy   has not been well researched; however, there are many options patients can try, including over-the-counter shampoos with pyrithione zinc, selenium sulfi de, salicylic acid, tar, or  antifungals   (e.g., Neutrogena T/Sal or T/Gel, or Nizoral). These shampoos should be used between one and three times weekly, depending on initial severity and rate of recurrence. For facial seborrheic dermatitis, the most effective prophylaxis comes with intermittent application of mild topical  corticosteroids   2–3 times weekly. Alternatively,  ketoconazole   2 % cream may be applied to the affected areas once per week, or ketoconazole 2 % shampoo can be used as a facial wash once per week, which may be especially useful if there is eye-brow involvement. Men with moustaches and beards who experience seborrheic der-matitis may use ketoconazole 2 % shampoo daily on their facial hair until the rash resolves, and once weekly for maintenance. As discussed earlier, seborrheic dermati-tis is often indistinguishable from mild  psoriasis  . If the diagnosis changes to psoriasis then the long-term management would be solely steroidal and not anti-fungal.   

Questions for the Dermatologist 

–  If this were seborrheic dermatitis alone (without impetigo), would it be appropriate to just treat with a topical steroid?  

Yes, topical  steroids      are a very successful treatment for seborrheic dermatitis. Mild topical steroids would be appropriate for use on the face. 

Overview   

Seborrheic dermatitis is a common, chronic cutaneous condition involving areas of the body with active sebaceous glands, such as the scalp, face, chest, and back. Its pathogenesis is controversial [ 1 ], and it has been associated with presence of yeast of the genus   Malassezia   . Many factors contribute to its pathogenesis.  Malassezia  metabolites, such as oleic acid, compromise the permeability of the skin barrier, becoming more susceptible to irritants and triggering an infl amma-tory response [ 1 ]. Seborrheic dermatitis, also sometimes called  seborrheic eczema  , may be classifi ed as a type of dermatitis, a  fungal infection  , or an infl ammatory process similar to  psoriasis .  

Seborrheic dermatitis occurs in 1–3 % of immunocompetent adults [ 1 ]. It also occurs more commonly in immunocompromised populations, such as patients who are HIV positive or have AIDS (34–83 % incidence), those with chronic alcoholic pancreatitis, hepatitis C virus, cardiac transplants, or various cancers, and patients with neurological conditions, such as Parkinson’s [ 1 – 3 ]. 

The onset of seborrheic dermatitis is commonly during infancy (when it is known as  cradle cap  ), puberty, young adulthood, and past the age of 50. It is more prevalent in men than women [ 2 ,  3 ].  

Presentation   

Seborrheic dermatitis is characterized by red,  fl aking   thin plaques. Presentation varies greatly in the degree of erythema,  fl aking  , pruritus, and greasy appearance of lesions [ 2 ]. It tends to be exacerbated by cold, dry weather and may improve during summer months. Lesions may appear on the  scalp  , forehead, eyebrows, nasolabial folds, folds behind the external ears, ear canals, and suprasternal area. Presentation on the scalp is usually restricted to scaling and fl aking. The retroauricular crease can have crusts and fi ssures.  

     Workup   

 The cause of seborrheic dermatitis is controversial, and many factors contribute to its development [ 2 ]. Accordingly lab workups may not necessarily be helpful. For example, a fungal culture may reveal the presence of  Malassezia    yeast  ; however, the yeast is present in most people regardless of whether they have seborrheic dermati-tis. A bacterial culture would rule out impetigo. 

 Histologically, seborrheic dermatitis has a characteristic spongiosis, which is intercellular edema in the epidermis, that renders it distinct from  psoriasis  .  

     Treatment   

 Several different medications may be used to treat seborrheic dermatitis as there are many factors that contribute to its pathogenesis. Topical anti-infl ammatory, such as  corticosteroids   and calcineurin inhibitors,  antifungal  , and keratolytic agents may be used. Topical azole  antifungals   are most effective in achieving long-term clearance, and topical steroids are most effective at reducing erythema, scaling and pruritus without unwanted side effects [ 4 ]. 

  Combination therapy   may provide the best approach to addressing multiple symp-toms. Our practice prescribes ketoconazole 2 % cream and desonide 0.05 % cream (Class VI) twice daily for 2 weeks to treat seborrheic dermatitis on the face (applied in any order). Combination therapy alternating ketoconazole 2 % shampoo and clobeta-sol propionate 0.05 % shampoo each twice weekly for 4 weeks demonstrates higher effi cacy than either shampoo alone in treating seborrheic dermatitis of the  scalp   [ 5 ].  

     Follow-Up   

 Seborrheic dermatitis tends to be a chronic and recurring condition. Treatment alle-viates symptoms but does not provide a cure, thus long-term maintenance plans are necessary.  Maintenance therapy   has not been well researched; however, there are many options patients can try, including over-the-counter shampoos with pyrithione zinc, selenium sulfi de, salicylic acid, tar, or  antifungals   (e.g., Neutrogena T/Sal or T/Gel, or Nizoral). These shampoos should be used between one and three times weekly, depending on initial severity and rate of recurrence. For facial seborrheic dermatitis, the most effective prophylaxis comes with intermittent application of mild topical  corticosteroids   2–3 times weekly. Alternatively,  ketoconazole   2 % cream may be applied to the affected areas once per week, or ketoconazole 2 % shampoo can be used as a facial wash once per week, which may be especially useful if there is eye-brow involvement. Men with moustaches and beards who experience seborrheic der-matitis may use ketoconazole 2 % shampoo daily on their facial hair until the rash resolves, and once weekly for maintenance. As discussed earlier, seborrheic dermati-tis is often indistinguishable from mild  psoriasis  . If the diagnosis changes to psoriasis then the long-term management would be solely steroidal and not anti-fungal.   

    Questions for the Dermatologist 

–  If this were seborrheic dermatitis alone (without impetigo), would it be appropri-

ate to just treat with a topical steroid?  

 Yes, topical  steroids      are a very successful treatment for seborrheic dermatitis. Mild topical steroids would be appropriate for use on the face. 

–  Can seborrheic dermatitis resolve with topical steroid alone or does it need anti-fungal treatment as well?  

 It can be controlled with topical steroids alone; however, it is likely to recur and usually requires long-term management. 

–  What topical steroids can be used on the face and for how long?  

 Topical steroids are classifi ed from I to VII, with VII being the weakest. Usually class V to VII steroids are appropriately weak. Desonide 0.05 % is a good example. It may be used twice daily for up to 2 weeks to resolve acute infl ammation, and can be used intermittently 2–3 times per week as long-term management. 

–  What happens if topical steroids are used for too long, or too much, on the face?  

 Lots of adverse effects can occur. Steroid-induced acne might be the fi rst to appear. Thinning of skin, and telangiectasias (spider veins) would likely occur, followed by suppression of the  hypothalamic–pituitary–adrenal (HPA)   axis. 

–  Does impetigo always require topical and oral antibiotic therapy?  

 It would depend on severity. Severe cases of impetigo may require oral antibiotics, while mild cases would likely resolve with topicals. It is always important to culture suspected  impetigo  . 

–  Do natural remedies like tea tree oil work? Are there alternative medicines that could help?  

 There are data to suggest  tea tree oil   is an effective antimicrobial agent against yeast and bacteria. Our practice does not use it as a stand alone therapy. It can be consid-ered as an adjunctive for those patients wanting a more holistic approach. 

–  Is seb derm of the    scalp     the same as what is commonly referred to as    dandruff    ?  

 Yes, they describe the same condition. However, seborrheic dermatitis can also affect the  penis  , chest, or face and it is not usually called  dandruff   in those cases.     

   References 

       1.   Dessinioti C, Katsambas A. Seborrheic dermatitis: etiology, risk factors, and treatments: facts and controversies. Clin Dermatol. 2013;31(4):343–51.

      2.    Gupta AK, Bluhm R. Seborrheic dermatitis. J Eur Acad Dermatol Venereol. 2004;18(1):13–26.  

     3.    Wolff K, Johnson RA, Suurmond D. Chapter 2, Eczema/dermatitis. In: Fitzpatrick’s color atlas & synopsis of clinical dermatology. 5th ed. New York: McGraw-Hill; 2005. p. 49–50.

    4.   Kastarinen H, Oksanen T, Okokon EO, Kiviniemi VV, Airola K, Jyrkkä J, Oravilahti T, Rannanheimo PK, Verbeek JH. Topical anti-infl ammatory agents for seborrhoeic dermatitis of the face or scalp (Review). Cochrane Database Syst Rev. 2014;5, CD009446. doi:  10.1002/14651858. CD009446.pub2    . 

    5.   Ortonne JP, Nikkels AF, Reich K, Ponce Olivera RM, Lee JH, Kerrouche N, Sidou F, Faergemann J. Effi cacious and safe management of moderate to severe scalp seborrhoeic der-matitis using clobetasol propionate shampoo 0.05% combined with ketoconazole shampoo 2%: a randomized, controlled study. Br J Dermtol. 2011;65(1):171–6.   

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