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Seborrheic Dermatitis, Emergency Medicine

Basics

Description

- Disease flares are common with physical and emotional stresses or illness - Factors predisposing patients to develop seborrheic dermatitis and more severe or refractory disease: - Parkinson disease - Paralysis - HIV/AIDS - Mood disorders including depression - Congestive heart failure - Immunosuppression in premature infants

- Blepharitis: - White scale adherent to eyelashes and eyelid margins with erythema - Resistant to treatment and persistent - May result in blepharoconjunctivitis

- Exacerbated by avoidance of washing - Usually bilateral, symmetrical, and favoring the following areas: - Scalp, forehead, eyebrows, eyelids - Areas of facial hair - External ear canals - Nasolabial and posterior auricular folds - Posterior neck - Presternal, navel, and body folds: - Axillary and inframammary regions - Groin and anogenital regions

- Atopic dermatitis: - Later onset in infants (usually >3 mo) - Characteristically affects antecubital and popliteal fossa in adults - Pruritus, oozing, and weeping support the diagnosis of atopic dermatitis - Family history of atopy (asthma and allergic rhinitis) favors atopic dermatitis - Axillary involvement favors the diagnosis of seborrheic dermatitis

- Contact dermatitis: - Polymorphous with erythema, edema, and vesicles - Tends to spare skin folds - May complicate seborrheic dermatitis as an unwanted reaction to treatment agents

- Cutaneous candidiasis: - Primary or secondary infection of the skin by Candida fungus - May affect any body area - Pruritus, erythema, mild scaling, and occasional blistering - Often associated with diabetes, obesity, or other illness - Common in infants - Presence of pseudohyphae on cytologic exam with potassium hydroxide does not exclude seborrheic dermatitis

- Langerhans cell histocytosis: - Systemic signs (e.g., fever and adenopathy) - Infants affected may display scaling - Reddish-brown papules or vesicles - Associated splenomegaly - Purpuric lesions

- Leiner disease: - Prevalent in infant females - Rapid onset in 2nd to 4th month of life - Deficiencies of complement C3, C5 - Severe generalized, exfoliative, erythrodermic form of seborrheic dermatitis - Fever, anemia, diarrhea, vomiting, weight loss, and failure to thrive

- Tinea versicolor (pityriasis versicolor): - Chronic superficial fungal disease usually located on the neck, upper arms, and trunk - Characterized by fine, scaly, coalescing, hypopigmented or hyperpigmented macules - Patient usually asymptomatic - Also associated with Malassezia yeast - Short, thick hyphae with spores (spaghetti-and-meatball pattern) seen on cytology with potassium hydroxide

- Pharmacologic options are often utilized in a multifaceted approach - Therapy is directed at decreasing the reservoir of lipophilic yeast and the sebum that supports its growth, thus reducing inflammation and improving hygiene - Severe cases may require removing scales and cornified nonviable epithelium to facilitate further treatment - Scales may be softened by applying mineral oil (overnight if necessary) prior to washing - Gentle brushing with a soft brush (toothbrush) or fine-tooth comb after washing may help remove stubborn scales - Patient education: - Early treatment when condition flares - Emphasize hygiene and demonstrate proper cleansing of scaly lesions - Moderate UV-A/UV-B sunlight exposure may be beneficial as it inhibits growth of Malassezia yeasts - Refrain from hair sprays and hair pomades

- Infantile seborrheic dermatitis: - Responds readily to shampoos, emollients, and mild topical steroids - Aggressive keratolytic or mechanical removal may cause further inflammation

- Imidazoles: - Inhibits ergosterol synthesis of fungal cell membrane - Target Malassezia species: - Ketoconazole 2% topical - Nizoral, Extina, Xolegel

- Topical corticosteroids: - Skin atrophy, striae, hypopigmentation, and telangiectasia may occur with extended use - Higher-potency agents indicated only for refractory conditions to less-potent agents - Use only briefly, as frequent use may foster recurrence and rebound effect - Use low-potency agents on areas with thinner skin (e.g., skin folds, neck, face): - Hydrocortisone 0.5%, 1%, 2.5%

- Consider high- to mid-potency agents only on areas of thicker skin (e.g., trunk, scalp): - Fluocinolone acetonide - Triamcinolone acetonide - Betamethasone dipropionate - Clobetasol propionate

- Coal tar/liquor carbonis detergens (LCD)*: - Inhibits mitotic cell division - Antipruritic, antiseptic properties - Reduces epidermal thickness - Avoid on face, skin flexures, or genitalia

- Topical calcineurin inhibitors: - Anti-inflammatory & antifungal properties - Lack long-term effects of corticosteroids - Black box warning concerning malignancy: - Pimecrolimus 1% - Tacrolimus 0.1%

  • A common and chronic papulosquamous inflammatory skin disorder
  • Affects all age groups and varies from mild dandruff to extensive adherent scale
  • Found in areas with high concentrations of sebaceous follicles and glands
  • Sharply demarcated yellow to red to brown, greasy, scaling, crusting patches/plaques
  • Periods of remission and exacerbation frequent in adults

Etiology

  • Exact pathogenesis not fully understood
  • Multifactorial with environmental, genetic, hormonal, immunologic, microbial, and nutritional influences
  • Strong association with Malassezia yeasts
  • Complex physiologic response:ImmunologicInflammatoryHyperproliferation
  • Disease flares are common with physical and emotional stresses or illness
  • Factors predisposing patients to develop seborrheic dermatitis and more severe or refractory disease:Parkinson diseaseParalysisHIV/AIDSMood disorders including depressionCongestive heart failureImmunosuppression in premature infants
  • Medications known to induce or aggravate seborrheic dermatitis include: View LargeArsenicInterferon-αAuranofinLithiumAurothioglucoseMethoxsalenBuspironeMethyldopaCarbamazepinePhenothiazinesChlorpromazinePhenytoinCimetidinePrimidoneEthionamidePsoralenGoldStanozololGriseofulvinThiothixeneHaloperidolTrioxsalen

Diagnosis

Signs and Symptoms

Infants

  • Onset during 1st few weeks of life, is usually self-limited and resolves by 12 mo of age
  • May present concurrently with atopic dermatitis
  • Flexural fold involvement may appear as diaper dermatitis:Frequently develops a bacterial or fungal superinfection
  • Cradle cap:Thick greasy, adherent scale concentrated on the vertex of the scalpAffects up to 70% of newborns during the 1st 3 mo of lifeMay be accompanied by inflammation or secondary infection

Young Children

  • Blepharitis:White scale adherent to eyelashes and eyelid margins with erythemaResistant to treatment and persistentMay result in blepharoconjunctivitis

Adolescents and Adults

  • Classic seborrheic dermatitis:Minor itching with greasy, fine, dry, white scaling overlying red, inflamed skin
  • Exacerbated by avoidance of washing
  • Usually bilateral, symmetrical, and favoring the following areas:Scalp, forehead, eyebrows, eyelidsAreas of facial hairExternal ear canalsNasolabial and posterior auricular foldsPosterior neckPresternal, navel, and body folds:Axillary and inframammary regionsGroin and anogenital regions
  • May cause areas of hypopigmentation in dark-skinned individuals

Essential Workup

Diagnosis is based on clinical history and physical exam

Diagnosis Tests & Interpretation

Lab

  • Potassium hydroxide preparations of skin scrapings may suggest yeast involvement
  • Fungal culture may help to exclude dermatophytosis as an alternate diagnosis

Imaging

None required

Diagnostic Procedures/Surgery

Skin biopsy (rarely required):

  • May help to exclude other diagnoses
  • Consider, if the diagnosis remains unclear or the condition fails to respond to treatment

Differential Diagnosis

  • Atopic dermatitis:Later onset in infants (usually >3 mo)Characteristically affects antecubital and popliteal fossa in adultsPruritus, oozing, and weeping support the diagnosis of atopic dermatitisFamily history of atopy (asthma and allergic rhinitis) favors atopic dermatitisAxillary involvement favors the diagnosis of seborrheic dermatitis
  • Contact dermatitis:Polymorphous with erythema, edema, and vesiclesTends to spare skin foldsMay complicate seborrheic dermatitis as an unwanted reaction to treatment agents
  • Cutaneous candidiasis:Primary or secondary infection of the skin by Candida fungusMay affect any body areaPruritus, erythema, mild scaling, and occasional blisteringOften associated with diabetes, obesity, or other illnessCommon in infantsPresence of pseudohyphae on cytologic exam with potassium hydroxide does not exclude seborrheic dermatitis
  • Dermatophytosis:Generally distributed asymmetricallyTinea capitis (scalp), corporis (body), cruris (groin), barbae (facial hair), faciei (face)Can be very difficult to distinguish from seborrheic dermatitisHyphae on cytologic exam with potassium hydroxide is suggestive of tinea
  • Langerhans cell histocytosis:Systemic signs (e.g., fever and adenopathy)Infants affected may display scalingReddish-brown papules or vesiclesAssociated splenomegalyPurpuric lesions
  • Leiner disease:Prevalent in infant femalesRapid onset in 2nd to 4th month of lifeDeficiencies of complement C3, C5Severe generalized, exfoliative, erythrodermic form of seborrheic dermatitisFever, anemia, diarrhea, vomiting, weight loss, and failure to thrive
  • Lupus erythematosus:Erythematous malar rash of the nose and malar eminencesChronic or discoid lupus:Discrete erythematous papules/plaquesThick adherent scale "Carpet tack " appearance if removed
  • Psoriasis:Thicker plaques with silvery white scalesLess likely confined to scalp
  • Rosacea:Usually with central facial erythema or forehead involvement
  • Tinea versicolor (pityriasis versicolor):Chronic superficial fungal disease usually located on the neck, upper arms, and trunkCharacterized by fine, scaly, coalescing, hypopigmented or hyperpigmented maculesPatient usually asymptomaticAlso associated with Malassezia yeastShort, thick hyphae with spores (spaghetti-and-meatball pattern) seen on cytology with potassium hydroxide

Infants with seborrheic dermatitis and cradle cap may present with concurrent atopic dermatitis

  • Seborrheic dermatitis is 1 of many conditions that may cause erythroderma (generalized exfoliative dermatitis):Severe scaling erythematous dermatitis involving 90% or more of the body

Treatment

Pre-Hospital

None required

Initial Stabilization/Therapy

None required

Ed Treatment/Procedures

  • Seborrheic dermatitis is a chronic condition:Emergent treatment is not required unless secondary infection or erythroderma is present

Medication

  • Pharmacologic options are often utilized in a multifaceted approach
  • Therapy is directed at decreasing the reservoir of lipophilic yeast and the sebum that supports its growth, thus reducing inflammation and improving hygiene
  • Severe cases may require removing scales and cornified nonviable epithelium to facilitate further treatment
  • Scales may be softened by applying mineral oil (overnight if necessary) prior to washing
  • Gentle brushing with a soft brush (toothbrush) or fine-tooth comb after washing may help remove stubborn scales
  • Patient education:Early treatment when condition flaresEmphasize hygiene and demonstrate proper cleansing of scaly lesionsModerate UV-A/UV-B sunlight exposure may be beneficial as it inhibits growth of Malassezia yeastsRefrain from hair sprays and hair pomades
  • Infantile seborrheic dermatitis:Responds readily to shampoos, emollients, and mild topical steroidsAggressive keratolytic or mechanical removal may cause further inflammation
  • Adult seborrheic dermatitis:Treatment aimed at controlling symptoms, rather than curing the condition
  • Blepharitis:Warm to hot compresses to affected areasGentle cleansing with baby shampoo and cotton tip debridement of thick scale
  • Cradle cap in infants:Topical olive oil (as emollient)Topical imidazolesLow-potency topical corticosteroids
  • Scalp findings in children & adults:Topical shampoos:Pyrithione zincCoal tarSalicylic acidSelenium sulfideCiclopiroxKetoconazole
  • Nonscalp findings in children & adults:Topical antifungals ± corticosteroidsTopical calcineurin inhibitors

First Line

  • Imidazoles:Inhibits ergosterol synthesis of fungal cell membraneTarget Malassezia species:Ketoconazole 2% topicalNizoral, Extina, Xolegel
  • Topical corticosteroids:Skin atrophy, striae, hypopigmentation, and telangiectasia may occur with extended useHigher-potency agents indicated only for refractory conditions to less-potent agentsUse only briefly, as frequent use may foster recurrence and rebound effectUse low-potency agents on areas with thinner skin (e.g., skin folds, neck, face):Hydrocortisone 0.5%, 1%, 2.5%Consider high- to mid-potency agents only on areas of thicker skin (e.g., trunk, scalp):Fluocinolone acetonideTriamcinolone acetonideBetamethasone dipropionateClobetasol propionate
  • Pyrithione zinc*:Reduces epidermal cell turnoverAntifungal & antibacterial properties
  • Salicylic acid*:Keratolytic propertiesUseful in areas where scaling and hyperkeratosis are prominent
  • Selenium sulfide*:Reduces epidermal and follicular corneocyte productionAntifungal properties
  • Coal tar/liquor carbonis detergens (LCD)*:Inhibits mitotic cell divisionAntipruritic, antiseptic propertiesReduces epidermal thicknessAvoid on face, skin flexures, or genitalia
  • Sulfur/sulfonamide combinations:Prevents PABA to folic acid conversion via dihydropteroate synthase inhibition:Carmol scalp treatmentOvace

*These agents are contained alone or in combination in formulations of the following:

  • Denorex
  • Head & Shoulders
  • Neutrogena T/Gel or T/Sal
  • Selsun Blue

Second Line

  • Ciclopirox:Anti-fungal, -bacterial, -inflammatory effects
  • Topical calcineurin inhibitors:Anti-inflammatory & antifungal propertiesLack long-term effects of corticosteroidsBlack box warning concerning malignancy:Pimecrolimus 1%Tacrolimus 0.1%

Follow-Up

Disposition

Admission Criteria

Admission unlikely to be required unless severe secondary infection or erythroderma is present

Discharge Criteria

Patients may be discharged with recommended medications and follow-up

Issues for Referral

  • Refer patients to primary care physician when considering underlying illness or comorbidities
  • Consider referral to a qualified dermatologist when the diagnosis remains elusive or the condition fails to respond to therapy

Follow-Up Recommendations

  • Symptoms should improve within 7 " 10 days, but may take months to resolve completely and may recur
  • Adolescent and adult forms may persist as a chronic dermatitis
  • Provide return precautions for signs of secondary bacterial or fungal infections:Fever, erythema, tenderness, or ulcerations

Pearls and Pitfalls

  • Severe and sudden attacks of seborrheic dermatitis may be the initial presentation of an immunocompromised patient (e.g., HIV/AIDS)
  • Admission may be warranted for further evaluation of the underlying disease process

Additional Reading

  • Elewski BE. Safe and effective treatment of seborrheic dermatitis. Cutis. 2009;83:333 " 338.
  • Goldsmith LA, Katz SI, Gilchrest BA, et al. Fitzpatricks Dermatology in General Medicine. 8th ed. New York, NY: McGraw-Hill; 2012.
  • Hurwitz S. Clinical Pediatric Dermatology. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2006.
  • Naldi L, Rebora A. Clinical practice. Seborrheic dermatitis. N Engl J Med. 2009;360:387 " 396.

Codes

ICD9

  • 690.10 Seborheic dermatitis, unspecified
  • 690.11 Seborrhea capitis
  • 690.12 Seborrheic infantile dermatitis
  • 690.18 Other seborrheic dermatitis
  • 690.1 Seborrheic dermatitis

ICD10

  • L21.0 Seborrhea capitis
  • L21.1 Seborrheic infantile dermatitis
  • L21.9 Seborrheic dermatitis, unspecified
  • L21.8 Other seborrheic dermatitis
  • L21 Seborrheic dermatitis

SNOMED

  • 50563003 Seborrheic dermatitis (disorder)
  • 200776003 Infantile seborrheic dermatitis (disorder)
  • 62742006 Cradle cap
  • 7297005 Generalized seborrheic dermatitis of infants (disorder)