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Therapeutic Strategies

Seborrheic Dermatitis

Timothy Berger Bruce Wintroub

Tuesday, January 01, 2013

Seborrheic dermatitis can be limited to the scalp, but it also can involve the face and any hairy or intertriginous area and rarely can even progress to a generalized erythroderma. Seborrheic dermatitis often forms a spectrum with psoriasis (sebopsoriasis), especially in HIV-infected persons. Seborrheic dermatitis coexists frequently with acne rosacea.

First Steps

Scalp:

  1. For moderate seborrheic dermatitis, prescribe an intermediate-potency steroid-containing solution (eg, triamcinolone acetonide 0.1% in propylene glycol, fluocinonide 0.05%, or betamethasone dipropionate 0.05% solution) to be applied nightly at bedtime. For best results, the solution should be streaked in 3 parallel rows (about 4-5 drops in each row) and massaged into the scalp. Clobetasol or betamethasone in a mousse formulation is a cosmetically acceptable alternatives that leaves the hair non-oily and easy to style.
  2. In addition to the topical steroid, shampoos with activity against P. ovale are used daily. Ketoconazole shampoo 1% (OTC) twice weekly plus a shampoo containing either zinc pyrithione or selenium sulfide on the other days is an effective strategy and often significantly reduces the need for topical steroids.
  3. For severe seborrheic dermatitis, the efficacy of the topical steroid can be enhanced by wearing an airtight plastic shower cap overnight after steroid application.

Face and body:

  1. Seborrheic dermatitis of nonscalp regions is extremely steroid-responsive, and therefore potent fluorinated steroids need not be used. Moreover, since the face and body folds are often involved, prescribe a nonfluorinated (nonatrophogenic) steroid (eg, desonide 0.5%, alclometasone dipropionate cream, or hydrocortisone 2.5% cream) to be applied twice daily or 3 times daily.
  2. Topical tacrolimus ointment and pimecrolimus cream are very effective for thin plaques of seborrheic dermatitis found on the face and body folds. They do not cause skin thinning or striae or exacerbate acne.

Ancillary Steps for More Recalcitrant Cases

  1. Baker's P&S or T/Gel lotion can be applied nightly at bedtime along with steroid solution to further loosen adherent scale.
  2. An acceptable tar-containing shampoo can be used daily. Since these preparations may produce some dryness of the hair, or impart a slight odor, patients may follow medicated shampoo treatments with a conditioner or cream rinse.
  3. Fluocinolone acetonide topical solution USP 0.01% solution applied nightly with a shower cap is effective in removing thick plaques of seborrheic dermatitis from the scalp. Often once-weekly or twice-weekly application is sufficient.

Subsequent Steps

  1. After initial treatment improvement, the goals of therapy are to reduce reliance on topical steroids and to maintain progress gained with medicated shampoos. Even when nonscalp areas are involved, ongoing therapy of scalp alone often will maintain progress, suggesting that "seeding" downward may be responsible for more widespread disease. By 2-4 weeks, patients often can be weaned off topical steroids, and maintained on regular shampooing with medicated shampoos alone.
  2. Seborrheic dermatitis coexists with acne rosacea, and the use of topical steroids on the rosacea may exacerbate the seborrheic dermatitis. Topical tacrolimus or pimecrolimus does not exacerbate acne rosacea and is very effective for thin plaques of seborrheic dermatitis. These are the agents of choice for the treatment of combined seborrheic dermatitis/rosacea.

Pitfalls

  1. In recalcitrant cases, rule out psoriasis or tinea capitis. Seborrheic dermatitis after infancy and before adolescence is rare (owing to inactivity of sebaceous glands). In contrast, tinea capitis is common in this age group. The presence of various degrees of hair loss is suggestive of tinea capitis. A fungal culture and/or scraping should be taken to exclude tinea in this age group before using corticosteroids on the scalp.
  2. In addition to the coexisting conditions described above, a seborrheic dermatitis-like picture can be the presenting feature of all forms of Langerhans' cell histiocytoses and other rare inherited or congenital disorders (eg, Hailey-Hailey disease, complement deficiencies).
  3. Seborrheic dermatitis tends to recur and relapse repeatedly; therefore, therapy with medicated shampoos (and often intermittent topical steroids as well) may need to be continued indefinitely.
  4. Potent topical steroid treatment of facial seborrheic dermatitis is frequently associated with the development of steroid rosacea. Sulfur-containing washes and creams will treat both acne rosacea and seborrhea and are useful in this setting.

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