Basics
Description
- 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:
- Immunologic
- Inflammatory
- Hyperproliferation
- 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
- Medications known to induce or aggravate seborrheic dermatitis include:
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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 scalp
- Affects up to 70% of newborns during the 1st 3 mo of life
- May be accompanied by inflammation or secondary infection
Young Children
- Blepharitis:
- White scale adherent to eyelashes and eyelid margins with erythema
- Resistant to treatment and persistent
- May 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, 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
- 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 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
- Dermatophytosis:
- Generally distributed asymmetrically
- Tinea capitis (scalp), corporis (body), cruris (groin), barbae (facial hair), faciei (face)
- Can be very difficult to distinguish from seborrheic dermatitis
- Hyphae on cytologic exam with potassium hydroxide is suggestive of tinea
- 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
- Lupus erythematosus:
- Erythematous malar rash of the nose and malar eminences
- Chronic or discoid lupus:
- Discrete erythematous papules/plaques
- Thick adherent scale
- "Carpet tack " appearance if removed
- Psoriasis:
- Thicker plaques with silvery white scales
- Less 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 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
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 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
- Adult seborrheic dermatitis:
- Treatment aimed at controlling symptoms, rather than curing the condition
- Blepharitis:
- Warm to hot compresses to affected areas
- Gentle cleansing with baby shampoo and cotton tip debridement of thick scale
- Cradle cap in infants:
- Topical olive oil (as emollient)
- Topical imidazoles
- Low-potency topical corticosteroids
- Scalp findings in children & adults:
- Topical shampoos:
- Pyrithione zinc
- Coal tar
- Salicylic acid
- Selenium sulfide
- Ciclopirox
- Ketoconazole
- Nonscalp findings in children & adults:
- Topical antifungals ± corticosteroids
- Topical calcineurin inhibitors
First Line
- 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
- Pyrithione zinc*:
- Reduces epidermal cell turnover
- Antifungal & antibacterial properties
- Salicylic acid*:
- Keratolytic properties
- Useful in areas where scaling and hyperkeratosis are prominent
- Selenium sulfide*:
- Reduces epidermal and follicular corneocyte production
- Antifungal properties
- Coal tar/liquor carbonis detergens (LCD)*:
- Inhibits mitotic cell division
- Antipruritic, antiseptic properties
- Reduces epidermal thickness
- Avoid on face, skin flexures, or genitalia
- Sulfur/sulfonamide combinations:
- Prevents PABA to folic acid conversion via dihydropteroate synthase inhibition:
- Carmol scalp treatment
- Ovace
*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 properties
- Lack long-term effects of corticosteroids
- Black 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)