Seborrheic Dermatitis

Treatment of seborrheic dermatitis of the scalp should include shampooing at least twice a week, because less frequent shampooing enables proliferation of Malassezia. Antifungal shampoos (eg, ketoconazole 2% or 1%) are highly effective in controlling the dandruff of seborrheic dermatitis. Because seborrheic dermatitis tends to be chronic and often recurs with cessation of treatment, long-term use of antifungal shampoos (eg, once or twice weekly) is often required. Keratolytic shampoos (zinc pyrithione, selenium sulfide, or sulfur and salicylic acid) and tar shampoos (available over the counter in the US) used daily or every other day until dandruff is controlled and twice/week thereafter are also helpful.

If antifungal and keratolytic shampoos fail to sufficiently relieve pruritus, topical corticosteroid solutions (eg, 0.01% fluocinolone acetonide solution) are used. Although the scalp is one of the areas least susceptible to the adverse effects of topical corticosteroids (eg, telangiectasia, atrophy, folliculitis, acne, striae distensae), adverse effects can occur with long-term use, so topical corticosteroids should be used only as needed.

Seborrheic dermatitis in beard and eyebrow areas is treated similarly to seborrheic dermatitis of the scalp. However, beard and eyebrow areas are more prone to the adverse effects of topical corticosteroids. Thus, corticosteroids should be used less frequently, and lower potency corticosteroid solutions (eg, 0.025% triamcinolone) should be used when possible.

For seborrheic dermatitis in nonterminal hair-bearing areas (eg, nasolabial folds, postauricular areas, sternum), treatment is similar. However, creams (which are typically not acceptable in hair-bearing areas) are preferred to solutions. For milder cases, 2% ketoconazole cream or other topical imidazoles applied twice daily are often sufficient. If not, mild topical corticosteroids (1 to 2.5% hydrocortisone cream, 0.2% hydrocortisone valerate cream) are applied twice daily. Higher potency topical corticosteroids are typically not required and should only be used short-term, if at all, because of the susceptibility of facial skin to the adverse effects of corticosteroids (eg, telangiectasia, atrophy, folliculitis/acne, perioral dermatitis). Calcineurin inhibitors (pimecrolimus and tacrolimus) are also effective, particularly when long-term use is necessary and antifungals alone are not sufficiently effective.

In infants, a baby shampoo is used daily, and 1 to 2.5% hydrocortisone cream or fluocinolone 0.01% oil can be used once to twice daily for redness and scaling on the scalp or face. Topical antifungals such as ketoconazole 2% cream or econazole 1% cream can also be helpful in severe cases.

For thick lesions on the scalp of a young child, mineral oil, olive oil, or a corticosteroid gel or oil is applied at bedtime to affected areas, for example, rubbed in with a toothbrush. The scalp is shampooed daily until the thick scale is gone.