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The Journal of Clinical and Aesthetic Dermatology

Matrix Medical Communications


Optimizing Treatment Approaches in Seborrheic Dermatitis
Goldenberg Gary, MD
Additional article information
Abstract
Seborrheic dermatitis is a chronic, recurring, cutaneous condition that causes
erythema and flaking, sometimes appearing as macules or plaues !ith dry !hite or
moist oily scales" #n adults, it commonly occurs in areas !ith high concentrations of
sebaceous glands" The face and scalp are the most freuently affected areas, and
in$ol$ement of multiple sites is common" Dandruff is regarded as a mild
noninflammatory form of seborrheic dermatitis" There is a high incidence of
seborrheic dermatitis among persons !ith human immunodeficiency $irus infection
or %arkinson&s disease" The cause of seborrheic dermatitis is not !ell understood,
but appears to be related to the composition of the sebaceous gland secretions, the
proliferation of Malessezia yeasts, and the host immune response" Treatment
options for nonscalp and scalp seborrheic dermatitis include topical agents and
shampoos containing antifungal agents, anti'inflammatory agents, keratolytic agents,
and calcineurin inhibitors" (ecause multiple body sites are usually in$ol$ed, the
physician should examine all commonly affected areas" %atients should be made
a!are that seborrheic dermatitis is a chronic condition that !ill probably recur e$en
after successful treatment"
1
Seborrheic dermatitis )SD*, a chronic, recurrent, inflammatory condition
characteri+ed by erythema and skin flaking, may be resistant to treatment and often
has a substantial negati$e impact on uality of life",-. #t affects approximately six
million people in the /nited States and is associated !ith direct and indirect medical
costs of approximately 01.2 million per year"3
Although the causes of SD are not completely understood, progress has been made
in this area, and se$eral effecti$e treatment options are a$ailable" This article !ill
re$ie! the clinical presentation of SD and the current understanding of its etiology
and discuss currently a$ailable treatment options"
2
CLINICAL PRESENTATION
Seborrheic dermatitis may appear as macules or thin plaues !ith a reddish or
yello! appearance and dry !hite or moist oily scales"4 #n adults, it most often occurs
in areas !ith a high concentration of sebaceous glands, including the face, scalp,
ears, chest, and body folds"4 #t usually affects multiple body areas, occurring on the
face in 55 percent of patients, the scalp in 62 percent, the chest in 16 percent, and
the arms or legs in , to 1 percent". #n more than half of patients !ith facial SD, the
scalp is affected as !ell". 7n the face, SD commonly occurs in the nasolabial folds,
eyebro!s, anterior hairline, and glabella",,8 7n the scalp, the lesions may range
from mild desuamation to bro!nish crusts affixed to the skin and hair"4 9esions on
the central chest may ha$e a petaloid appearance"6 Some patients report pruritus,
particularly if the scalp is affected"1,4,8 #t generally is not accompanied by papules or
pustules"1Secondary bacterial infection may occur, aggra$ating erythema and
exudate and causing local discomfort"4
#n adults, SD is a chronic, recurrent condition marked by periods of exacerbation
occurring at $ariable inter$als"8 %atients may report that outbreaks are triggered by
emotional stress, depression, fatigue, exposure to air conditioning or damp or dry
conditions in the !orkplace, systemic infections, use of certain medications, or other
factors".
The infantile form of SD is a self'limited condition generally resol$ing by age three or
four months"8 The adult form usually appears first around the time of puberty, !hen
sebaceous glands become more acti$e, sometimes lasting until young
3
adulthood", The condition increases again in pre$alence after age 42", #t affects
approximately , to 4 percent of immunocompetent adults and as many as 12 to 5.
percent of human immunodeficiency $irus ):#;*'positi$e indi$iduals"4,8 7ther
populations at risk include persons !ith %arkinson&s disease or other neurological
disorders, mood disorders, significant life stress, or lo! exposure to sunlight"1 More
men than !omen ha$e SD, but it sho!s no preference for any racial or ethnic
group"8 #t may occur in association !ith atopic dermatitis or other skin disorders,
complicating its diagnosis"5
Some contro$ersy has surrounded the relationship bet!een SD and dandruff" Most
authors no! agree that dandruff is a mild, noninflammatory form of
SD"1,8,< Dandruff is extremely common, !ith a pre$alence as high as 42 percent of
the population"1
CAUSES OF SEBORREIC DER!ATITIS
Although the causes of SD are not completely understood, it appears to result from a
combination of the follo!ing three factors= sebaceous gland secretion, presence
ofMalassezia yeast, and the host immune response"8
Sebum is an important component of skin surface lipids and contains high amounts
of sualene, !ax esters, and triglycerides",2 %ersons !ith SD do not necessarily
ha$e excess sebaceous gland acti$ity, but the composition of their skin surface lipid
may be altered, creating a more supporti$e en$ironment for gro!th of lipid'
dependent micro'organisms",2
4
The role of Malassezia yeasts in SD is some!hat contro$ersial, although most
researchers belie$e they play an important role"< Malassezia yeasts are normally
commensal species found primarily in follicular infundibula and commonly isolated
from sebum'rich areas of the body, such as the face, scalp, trunk, and back",, They
produce abundant lipases that hydroly+e triglycerides and free saturated fatty acids
on !hich the yeast is dependent",1 These fatty acids may ha$e irritant effects that
induce scaling or may cause release of arachidonic acid, !hich promotes
inflammation in skin"< There are se$en primary species= M. globosa, M. restricta, M.
obtusa, M. sloojjiae, M. sympodialis, M. jurjur, and M. pachydermatis )the last occurs
only on animals*"< M. globosa and M. restricta are thought to be the species most
commonly associated !ith SD, although M. jurjur and other species ha$e also been
implicated"<,,.,,3 Some studies ha$e found high numbers of Malassezia yeasts on
the scalp of persons !ith SD, but others ha$e found no difference in the density of
these yeasts bet!een the skin of persons !ith SD and that of persons !ithout
it", Differing sampling methods may contribute to these contradictory
findings" Malassezia exist not only on the skin surface, but also !ithin the layers of
the stratum corneum, and a true count !ould reuire examining the full thickness of
the skin suama", Support for the role of Malassezia in SD comes from studies
demonstrating that use of $arious antifungal treatments results in reduction
of Malassezia, !hich is accompanied by impro$ement in symptoms"8,<
The role of the host immune response in the pathogenesis of SD is uncertain" Some
researchers ha$e reported increased numbers of natural killer cells, CD,8 cells, and
5
inflammatory interleukins and acti$ation of complement in the lesional skin of
patients !ith SD compared !ith their o!n nonlesional skin or the skin of healthy
controls"8 >e$ertheless, total antibody le$els are no higher in SD patients than in
controls and a host response specific to Malassezia yeasts has not been
identified"<The pre$alence of SD in persons infected !ith :#; suggests that the
condition is mediated by the immune system? ho!e$er, the response of SD to
successful retro$iral therapy is $ariable"4
Thus, a definiti$e understanding of the pathophysiology of SD a!aits further
research, but the role of Malassezia yeasts as causati$e or contributing agents
appears to be !ell established"
DIA"NOSIS
The differential diagnosis of SD should include psoriasis,
rosacea, Demodex dermatitis, atopic ec+ema, pityriasis $ersicolor, contact
dermatitis, and tinea infections"1 SD may also resemble 9angerhans cell
histiocytosis or secondary syphilis"1,4 The diagnosis is usually clinical, but
candidiasis, tinea infection, and Demodex dermatitis may be ruled out !ith a
negati$e potassium hydroxide test"1 #t should be kept in mind that SD may be
accompanied by other dermatological disorders"
Care should be taken to differentiate SD from psoriasis $ulgaris",4 @arly SD has a
spongiform appearance that distinguishes it from psoriasis, but in later stages these
conditions are more difficult to tell apart" Some patients present !ith sebopsoriasis,
6
!hich includes features of both disease states"1 9esions on the elbo!s or knees and
nail pitting suggest psoriasis, !hich may spare the face",4
TREAT!ENT
The primary goals of therapy for SD are to clear the $isible signs of disease and
reduce bothersome symptoms, especially pruritus"8 (ecause the face and scalp are
the most commonly affected areas, itching or redness on the scalp in a patient !ith
facial SD indicates the need for treatment at both sites". %atients should be informed
that SD is a chronic, relapsing condition and that they should anticipate future
outbreaks",8 %atients should also be ad$ised to a$oid triggers of SD symptoms to
the extent possible and not to irritate the lesions by excessi$e scratching or use of
potent keratolytic preparations",8,,6
NONSCALP SEBORREIC DER!ATITIS
Antifungal agents, anti'inflammatory agents, and keratolytic agents are a$ailable in a
$ariety of formulations for treatment of SD on areas other than the scalp" Table , lists
commonly used treatments for nonscalp SD and indicates the le$el of e$idence that
supports their use"
TA(9@ ,
Treatments for nonscalp seborrheic dermatitis
7
Antifungal agents. Aith the understanding of the role of Malassezia in SD,
antifungal agents ha$e taken on an important role in its treatment" Betocona+ole 1C
cream applied t!ice daily for four !eeks has been sho!n to be as effecti$e as
hydrocortisone ,C cream in treatment of SD at multiple body sites",5 #n a
randomi+ed, double'blind trial of 34< patients !ith SD treated !ith ketocona+ole 1C
gel or $ehicle once daily for ,3 days, there !as a significantly higher rate of
successful treatment )14".C $s" ,."<C,PD2"22,3* and significantly greater
reductions in erythema, pruritus, and scaling in ketocona+ole'treated patients",< A
1C foam formulation of ketocona+ole has been sho!n to be significantly more
effecti$e than $ehicle for treatment of SD on the face, scalp, and body, and eually
as effecti$e as ketocona+ole 1C cream"12
Ciclopiroxolamine ,C cream, t!ice daily for 15 days follo!ed by once daily for 15
days, !as compared !ith $ehicle for the treatment of SD in a randomi+ed,
doubleblind trial that enrolled ,1< patients"1, At the end of the maintenance phase,
complete disappearance of erythema and scaling !as found in 8. percent of the
ciclopiroxolamine'treated group and .3 percent of the $ehicle'treated group
)PE2"226*"1,
#n an open'label study of sertacona+ole nitrate 1C cream, 4< percent of 12 subFects
!ith mild'to'se$ere SD !ere successfully treated, !ith impro$ements in scaling,
erythema, induration, and pruritus"11
8
A randomi+ed, double'blind study demonstrated that metronida+ole 2"64C gel is as
effecti$e as ketocona+ole 1C cream in treatment of facial SD, !ith a similar side
effect profile"1.
Gor patients !ith persistent SD resistant to topical agents, oral antifungals may be an
option" 7ral itracona+ole gi$en in a dose of 122mgHday for one !eek, follo!ed by a
maintenance dose, resulted in clinical impro$ement of SD symptoms in t!o open'
label trials"13,14
Corticosteroids. :ydrocortisone and a !ide $ariety of other lo!' to mid'potency
corticosteroids ha$e been used successfully in the treatment of SD" A double'blind
study that compared hydrocortisone ,C cream !ith ketocona+ole 1C cream in 61
patients !ith mild'to'moderate SD found that the t!o agents produced similar rates
of response and similar reductions in scaling, redness, itching, and papules"18 #n a
,1'!eek, single'blind, randomi+ed, comparati$e trial, hydrocortisone ,C ointment
!as found to be eually as effecti$e as tacrolimus 2",C ointment in reducing the
symptoms of facial SD by physician assessment, although tacrolimus !as superior
by patient assessment"16
Combination antifungal/anti-inflammatory. %romisebI Topical Cream )%romius
%harma, 99C, (ridge!ater, >e! Jersey* is a nonsteroidal prescription medical
de$ice !ith anti'inflammatory and antifungal acti$ity appro$ed for treatment of
SD"15 #n an in$estigator'blind, parallel'group study, 66 patients !ith mild or
moderate SD of the face !ere randomi+ed to combination antifungalHanti'
inflammatory cream or desonide 2"24C cream t!ice daily for up to 15
9
days"1< Se$erity of symptoms declined significantly from baseline to Day ,3 and
Day 15 in both groups"1< Treatment !as successful )clear or almost clear* in 54
percent of patients using combination antifungalHanti'inflammatory cream and <1
percent of patients using desonide cream )PDnot significant* and the t!o products
had similar safety profiles"1<
Calcineurin inhibitors. Topical calcineurin inhibitors ha$e immunomodulatory and
anti'inflammatory properties that make them useful in the treatment of SD"16
Tacrolimus 2",C ointment !as found to be as effecti$e as hydrocortisone ,C
ointment in the treatment of SD, reuired fe!er applications during the ,1'!eek
study period because of clearing of symptoms, and !as rated more fa$orably by
patients"16
#n a randomi+ed, open'label trial, pimecrolimus ,C cream !as compared !ith
betamethasone 2",C cream in 12 patients !ith SD !ho !ere instructed to
discontinue treatment !hen symptoms cleared".2 (y Day <, all patients had
discontinued treatment".2 The t!o drugs !ere eually effecti$e at reducing
symptoms of erythema, scaling, and pruritus, but symptom relief !as sustained
longer in the pimecrolimus group".2 #n comparati$e trials, pimecrolimus ,C cream
has been sho!n to be as effecti$e as hydrocortisone ,C cream and ketocona+ole
1C cream in the treatment of SD, !ith higher rates of ad$erse
effects".,,.1 %imecrolimus ,C cream !as found to be significantly more effecti$e for
treatment of facial SD than methylprednisolone 2",C cream or metronida+ole 2"64C
10
gel !hen applied t!ice daily for eight !eeks, !ith fe!er ad$erse effects and a lo!er
rate of recurrence than metronida+ole"..
SCALP SEBORREIC DER!ATITIS
Seborrheic dermatitis of the scalp is most con$eniently treated !ith shampoos
containing antifungal agents, corticosteroids, or keratolytic agents? products are also
a$ailable that combine drugs from these different classes" Table 1 lists commonly
used treatments for SD of the scalp and indicates the le$el of e$idence that supports
their use"
TA(9@ 1
Treatments for seborrheic dermatitis of the scalp
Antifungal shampoos. Betocona+ole 1C shampoo !as compared !ith selenium
sulfide 1"4C shampoo in a four'!eek, randomi+ed, double'blind trial of patients !ith
moderate'to'se$ere dandruff".3 T!ice'!eekly use of either shampoo !as superior to
placebo, but not significantly different from each other".3 There !as a significantly
higher incidence of ad$erse effects among patients using selenium sulfide
shampoo".3
Ciclopirox ,C shampoo used once or t!ice !eekly for four !eeks !as sho!n to be
superior to $ehicle for treatment of SD in a randomi+ed, double'blind, controlled
11
study that recruited <3< patients".4 Subseuent prophylactic use of ciclopirox
shampoo once !eekly or once e$ery t!o !eeks reduced the relapse rate".4
Ciclopirox shampoo and ketocona+ole shampoo !ere compared in a double'blind
study of .42 patients !ith SD".8 The t!o treatments !ere eually effecti$e and both
better than placebo, although patients rated the ciclopirox shampoo more
fa$orably".8
Corticosteroid shampoos. #n a randomi+ed, single'blind study of .18 subFects !ith
moderate'to'se$ere scalp SD, clobetasol propionate 2"24C shampoo t!ice !eekly
for four !eeks produced a significantly greater reduction in symptoms than
ketocona+ole 1C shampoo".6 Alternating use of clobetasol shampoo and
ketocona+ole shampoo !as also superior to ketocona+ole shampoo alone".6
Combination products. %romisebI %lus Scalp Aash )%romius %harma, 99C*
contains surfactants and skin conditioning agents, !hich remo$e excess sebum as
!ell as lactoferrin and piroctone olamine, !hich may reduce the proliferation
ofMalassezia".5 #n an open'label trial, 14 subFects !ith SD used this proprietary
!ash an a$erage of t!ice !eekly for t!o !eeks".5 All 14 had a positi$e response
and more than <2 percent reported impro$ement in seborrhea, dandruff, pruritus,
and redness".5
#n a single'blind study, a shampoo containing ciclopiroxolamine ,"4C and salicylic
acid .C !as sho!n to ha$e efficacy similar to that of ketocona+ole 1C shampoo for
12
the treatment of dandruffHSD".< Gor both groups, impro$ement !as sustained for ,3
days after treatment ended".<
A shampoo containing ciclopiroxolamine ,"4C and +inc pyrithione ,C !as found to
be as effecti$e as ketocona+ole 1C foaming gel in a single'blind study of ,5<
patients !ith scalp SD, !ith a greater reduction in pruritus during the early treatment
phase and more fa$orable ratings from patients"32
Keratolytic products. A randomi+ed, double'blind study compared a shampoo
containing lipohydroxy acid 2",C and salicylic acid ,".C !ith a shampoo containing
ciclopiroxolamine ,"4C and salicylic acid .C in ,22 subFects !ith scalp SD"3, After
four !eeks of treatment, the tolerance, global efficacy, and cosmetic effects of the
lipohydroxy acid shampoo !ere significantly superior to those of the
ciclopiroxolamine shampoo"3,
A topical solution of urea, propylene glycol, and lactic acid, applied daily for four
!eeks then three times per !eek for four !eeks, !as compared !ith placebo for
treatment of mild'to'se$ere SD of the scalp"31 @rythema and desuamation !ere
impro$ed at Aeeks 1 and 3, but the impro$ements !ere not maintained at eight
!eeks"31
CONCLUSION
Seborrheic dermatitis is a common, chronic, inflammatory cutaneous condition
characteri+ed by erythema and skin flaking that tends to recur e$en after successful
treatment and has a significant negati$e impact on uality of life" #ts occurrence
13
appears to be related to the proliferation of commensal Malassezia species"
7ccurrence at multiple body sites is common? the face and scalp are the most
freuently affected areas" >umerous antifungal, anti'inflammatory, keratolytic, and
immunomodulatory agents ha$e been sho!n to be effecti$e in the treatment of SD,
but patients should be informed that recurrence is common and that ongoing
treatment may be necessary"
Footnotes
DISCLOSURE: Dr# "o$%enberg reports no re$e&ant con'$icts o' interest# !an(script %e&e$opment )as
s(pporte% b* Promi(s Pharma+ LLC#
Artic$e in'ormation
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ADDRESS CORRESPONDENCE TO: "ar* "o$%enberg+ !D+ 9 East 8;th St+ Bo> /.6;+ Ne) <or=+ N<
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