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.
- 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.
- 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.
- 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:
- 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.
- 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
Ancillary Steps for More Recalcitrant
- Baker's P&S or T/Gel lotion can be applied nightly at
bedtime along with steroid solution to further loosen adherent
- 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.
- 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.
- 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.
- 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.
- 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.
- 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,
- 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
- 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.