BASICS
DESCRIPTION
Chronic, superficial, recurrent inflammatory rash affecting sebum-rich, hairy regions of the body, especially the scalp, eyebrows, and face
EPIDEMIOLOGY
Incidence
- Predominant age: infancy, adolescence, and adulthood
- Predominant sex: male > female
Prevalence
Seborrheic dermatitis: 3-5%
ETIOLOGY AND PATHOPHYSIOLOGY
- Skin surface yeasts Malassezia (formerly Plasmodium ovale) may be a contributing factor (1,2).
- The mite Demodex folliculorum may have a direct/indirect role (3).
- Genetic and environmental factors: Flares are common with stress/illness.
- Parallels increased sebaceous gland activity in infancy and adolescence or as a result of some acnegenic drugs.
- Seborrheic dermatitis is more common in immunosuppressed patients, suggesting that immune mechanisms are implicated in the pathogenesis of the disease, although the mechanisms are not well defined (1).
Genetics
Positive family history; no genetic marker is identified to date.
RISK FACTORS
- Parkinson disease
- AIDS (disease severity correlated with progression of immune deficiency)
- Emotional stress
- Medications may flare/induce seborrheic dermatitis: auranofin, aurothioglucose, buspirone, chlorpromazine, cimetidine, ethionamide, gold, griseofulvin, haloperidol, interferon-α, lithium, methoxsalen, methyldopa, phenothiazine, psoralen, stanozolol, thiothixene, trioxsalen (2)
GENERAL PREVENTION
Seborrheic skin should be washed more often than usual.
COMMONLY ASSOCIATED CONDITIONS
DIAGNOSIS
Diagnosis of seborrheic dermatitis usually can be made by history and physical exam.
HISTORY
- Intermittent active phases manifest with burning, scaling, and itching, alternating with inactive periods; activity is increased in winter and early spring, with remissions commonly occurring in summer.
- Infants
- Cradle cap: greasy scaling of scalp, sometimes with associated mild erythema
- Diaper and/or axillary rash
- Age at onset typically ~1 month
- Usually resolves by 8 to 12 months
- Adults
- Red, greasy, scaling rash in most locations consisting of patches and plaques with indistinct margins
- Red, smooth, glazed appearance in skin folds
- Minimal pruritus
- Chronic waxing and waning course
- Bilateral and symmetric
- Most commonly located in hairy skin areas: scalp and scalp margins, eyebrows and eyelid margins, nasolabial folds, ears and retroauricular folds, presternal area, middle to upper back, buttock crease, inguinal area, genitals, and armpits
PHYSICAL EXAM
- Scalp appearance varies from mild, patchy scaling to widespread, thick, adherent crusts. Plaques are rare.
- Seborrheic dermatitis can spread onto the forehead, the posterior part of the neck, and the postauricular skin, as in psoriasis.
- Skin lesions manifest as brawny or greasy scaling over red, inflamed skin.
- Hypopigmentation is seen in African Americans.
- Infectious eczematoid dermatitis, with oozing and crusting, suggests secondary infection.
- Seborrheic blepharitis may occur independently.
DIFFERENTIAL DIAGNOSIS
- Atopic dermatitis: Distinction may be difficult in infants.
- Psoriasis
- Usually knees, elbows, and nails are involved.
- Scalp psoriasis will be more sharply demarcated than seborrhea, with crusted, infiltrated plaques rather than mild scaling and erythema.
- Candida
- Tinea cruris/capitis: Suspect these when usual medications fail/hair loss occurs.
- Eczema of auricle/otitis externa
- Rosacea
- Discoid lupus erythematosus: Skin biopsy will be beneficial.
- Histiocytosis X: may appear as seborrheic-type eruption
- Dandruff: scalp only, noninflammatory
DIAGNOSTIC TESTS & INTERPRETATION
Diagnostic Procedures/Other
Consider biopsy if
- Usual therapies fail
- Petechiae is noted.
- Histiocytosis X is suspected.
- Fungal cultures in refractory cases or when pustules and alopecia are present.
Test Interpretation
Nonspecific changes
- Hyperkeratosis, acanthosis, accentuated rete ridges, focal spongiosis, and parakeratosis are characteristic.
- Parakeratotic scale around hair follicles and mild superficial inflammatory lymphocytic infiltrate
TREATMENT
GENERAL MEASURES
- Increase frequency of shampooing.
- Sunlight in moderate doses may be helpful.
- Cradle cap
- Frequent shampooing with a mild, nonmedicated shampoo
- Remove thick scale by applying warm mineral oil, then wash off 1 hour later with a mild soap and a soft-bristle toothbrush or terrycloth washcloth.
- Adults: Wash all affected areas with antiseborrheic shampoos. Start with over-the-counter products (selenium sulfide) and increase to more potent preparations (containing coal tar, sulfur, or salicylic acid) if no improvement is noted.
- For dense scalp scaling, 10% liquor carbonic detergens in Nivea oil may be used at bedtime, covering the head with a shower cap. This should be done nightly for 1 to 3 weeks.
MEDICATION
First Line
- Cradle cap: Use a coal tar shampoo or ketoconazole (Nizoral) shampoo if the nonmedicated shampoo is ineffective.
- Adults
- Topical antifungal agents
- Ketoconazole or miconazole 2% shampoo twice a week for clearance, then once a week or every other week for maintenance (1,4,5 and 6)[A]
- Ketoconazole (Nizoral) and sertaconazole 2% cream may be used to clear scales in other areas (1,4,5 and 6)[A].
- Ciclopirox 1% shampoo twice weekly (1)[A]
- Topical corticosteroids
- Begin with 1% hydrocortisone and advance to more potent (fluorinated) steroid preparations, as needed (1,4,5 and 6)[A].
- Avoid continuous use of the more potent steroids to reduce the risk of skin atrophy, hypopigmentation, or systemic absorption (especially in infants and children).
- Precautions: Fluorinated corticosteroids and higher concentrations of hydrocortisone (e.g., 2.5%) may cause atrophy or striae if used on the face or on skin folds.
- Other topical agents
- Coal tar 1% shampoo twice a week
- Selenium sulfide 2.5% shampoo twice a week (1,4,5 and 6)[A]
- Zinc pyrithione shampoo twice a week
- Lithium succinate ointment twice a week
- Once controlled, washing with zinc soaps or selenium lotion with periodic use of steroid cream may help to maintain remission.
Second Line
- Calcineurin inhibitors
- Pimecrolimus 1% cream BID (7)[B]
- Tacrolimus 0.1% ointment BID (1,4,5 and 6)[A]
- Systemic antifungal therapy
- Data are limited.
- For moderate to severe seborrheic dermatitis
- Ketoconazole: 200 mg/day (8)[A]
- Itraconazole: 200 mg/day (8)[A]
- Daily regimen for 1 to 2 months followed by twice-weekly dosing for chronic treatment
- Monitor potential hepatotoxic effects.
- Low-molecular-weight hyaluronic acid
- Hyaluronic acid sodium salt gel 0.2% BID (9)[B]
ISSUES FOR REFERRAL
No response to first-line therapy and concerns regarding systemic illness (e.g., HIV)
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Every 2 to 12 weeks, as necessary, depending on disease severity and degree of patient sophistication
PATIENT EDUCATION
http://familydoctor.org/familydoctor/en/diseases-conditions/seborrheic-dermatitis.html
PROGNOSIS
- In infants, seborrheic dermatitis usually remits after 6 to 8 months.
- In adults, seborrheic dermatitis is usually chronic and unpredictable, with exacerbations and remissions. Disease is usually easily controlled with shampoos and topical steroids.
COMPLICATIONS
- Skin atrophy/striae is possible from fluorinated corticosteroids, especially if used on the face.
- Glaucoma can result from use of fluorinated steroids around the eyes.
- Photosensitivity is caused occasionally by tars.
- Herpes keratitis is a rare complication of herpes simplex: Instruct patient to stop eyelid steroids if herpes simplex develops.
REFERENCES
11 Dessinioti C, Katsambas A. Seborrheic dermatitis: etiology, risk factors, and treatment: facts and controversies. Clin Dermatol. 2013:31(4):343-351.22 Hay RJ. Malassezia, dandruff and seborrhoeic dermatitis: an overview. Br J Dermatol. 2011;165(Suppl 2):2-8.33 Karincaoglu Y, Tepe B, Kalayci B, et al. Is Demodex folliculorum an aetiological factor in seborrhoeic dermatitis? Clin Exp Dermatol. 2009;34(8):e516-e520.44 Clark GW, Pope SM, Jaboori KA. Diagnosis and treatment of seborrheic dermatitis. Am Fam Physician. 2015;91(3):185-190.55 Stefanaki I, Katsambas A. Therapeutic update on seborrheic dermatitis. Skin Therapy Lett. 2010;15(5):1-4.66 Kastarinen H, Oksanen T, Okokon EO, et al. Topical anti-inflammatory agents for seborrheic dermatitis of the face or scalp. Cochrane Database Syst Rev. 2014;(5):CD009446.77 Kim GK, Rosso JD. Topical pimecrolimus 1% cream in the treatment of seborrheic dermatitis. J Clin Aesthet Dermatol. 2013;6(2):29-35.88 Gupta AK, Richarson M, Paquet M. Systematic review of oral treatments for seborrheic dermatitis. J Eur Acad Dermatol Venereol. 2014:28(1):16-26.99 Schlesinger T, Rowland Powell C. Efficacy and safety of a low molecular weight hyaluronic acid topical gel in the treatment of facial seborrheic dermatitis final report. J Clin Aesthet Dermatol. 2014:7(5):15-18.
ADDITIONAL READING
- Bikowski J. Facial seborrheic dermatitis: a report on current status and therapeutic horizons. J Drugs Dermatol. 2009;8(2):125-133.
- Darabi K, Hostetler SG, Bechtel MA, et al. The role of Malassezia in atopic dermatitis affecting the head and neck of adults. J Am Acad Dermatol. 2009;60(1):125-136.
- Johnson BA, Nunley JR. Treatment of seborrheic dermatitis. Am Fam Physician. 2000;61(9):2703-2710, 2713-2714.
- Naldi L, Rebora A. Clinical practice. Seborrheic dermatitis. N Engl J Med. 2009;360(4):387-396.
- Shemer A, Kaplan B, Nathansohn N, et al. Treatment of moderate to severe facial seborrheic dermatitis with itraconazole: an open non-comparative study. Isr Med Assoc J. 2008;10(6):417-418.
SEE ALSO
Algorithm: Rash, Focal
CODES
ICD10
- L21.9 Seborrheic dermatitis, unspecified
- L21.1 Seborrheic infantile dermatitis
- L21.0 Seborrhea capitis
- L21.8 Other seborrheic dermatitis
ICD9
- 690.10 Seborrheic dermatitis, unspecified
- 690.12 Seborrheic infantile dermatitis
- 690.11 Seborrhea capitis
- 690.18 Other seborrheic dermatitis
SNOMED
- 50563003 Seborrheic dermatitis (disorder)
- 200776003 Infantile seborrheic dermatitis (disorder)
- 62742006 Cradle cap
- 402204009 Chronic seborrheic dermatitis (disorder)
CLINICAL PEARLS
- Search for an underlying systemic disease in a patient who is unresponsive to usual therapy.
- In adults, seborrheic dermatitis is usually chronic and unpredictable, with exacerbations and remissions. Disease is usually easily controlled with shampoos and topical steroids.