AUTHOR INFORMATION

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Authored by Samuel T Selden, MD, Assistant Professor of Clinical Internal Medicine, Eastern Virginia Medical School; Consulting Staff, Chesapeake General Hospital; Private Practice

Samuel T Selden, MD, is a member of the following medical societies: American Academy of Dermatology

Edited by Robin Travers, MD, Professor, Department of Dermatology, Boston University School of Medicine; Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA; Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, Medicine, University of Texas Health Science Center-San Antonio; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; and William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

Author's Email:	Samuel T Selden, MD
Editor's Email:	Robin Travers, MD

eMedicine Journal, March 14 2007, VOLUME 8, Number 3

INTRODUCTION

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Background: Seborrheic dermatitis is a papulosquamous disorder patterned on the sebum-rich areas of the scalp, face, and trunk. In addition to sebum, this dermatitis is linked to Malassezia, immunologic abnormalities, and activation of complement. It is commonly aggravated by changes in humidity, changes in seasons, trauma (eg, scratching), or emotional stress. The severity varies from mild dandruff to exfoliative erythroderma. Seborrheic dermatitis may worsen in Parkinson disease and in AIDS.

Pathophysiology: Seborrheic dermatitis is associated with normal levels of Malassezia but an abnormal immune response. Helper T cells, phytohemagglutinin and concanavalin stimulation, and antibody titers are depressed compared with those of control subjects. The contribution of Malassezia may come from its lipase activity—releasing inflammatory free fatty acids—and from its ability to activate the alternative complement pathway.

Frequency:

• Internationally: The prevalence rate of seborrheic dermatitis is 3-5%, with a worldwide distribution. Dandruff, the mildest form of this dermatitis, is probably far more common and is present in an estimated 15-20% of the population.

Race: Seborrheic dermatitis occurs in persons of all races.

Sex: The condition is slightly worse in males than in females.

Age: The usual onset occurs with puberty.

• It peaks at age 40 years and is less severe, but present, among older people.

• In infants, it occurs as cradle cap or, uncommonly, as a flexural eruption or erythroderma.

CLINICAL

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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.



• Active phases may be complicated by secondary infection in the intertriginous areas and on the eyelids.



• Candidal overgrowth is common in infantile napkin dermatitis. Such children may have a diaper dermatitis variant of seborrheic dermatitis or psoriasis.



• Generalized seborrheic erythroderma is rare. It occurs more often in association with AIDS, congestive heart failure, Parkinson disease, and immunosuppression in premature infants.

Physical:

• Scalp appearance varies from mild, patchy scaling to widespread, thick, adherent crusts. Plaques are rare. From the scalp, seborrheic dermatitis can spread onto the forehead, the posterior part of the neck, and the postauricular skin, as in psoriasis.



• Skin lesions manifest as branny or greasy scaling over red, inflamed skin. Hypopigmentation is seen in blacks. Infectious eczematoid dermatitis, with oozing and crusting, suggests secondary infection. A seborrheic blepharitis may occur independently.



• Distribution follows the oily and hair-bearing areas of the head and the neck, such as the scalp, the forehead, the eyebrows, the lash line, the nasolabial folds, the beard, and the postauricular skin. An extension to submental skin can occur. Presternal or interscapular involvement is more common than nonscaling intertrigo of the umbilicus, axillae, inframammary and inguinal folds, perineum, or anogenital crease, which also may be present.



• Two distinct truncal patterns can occasionally occur. An annular or geographic petaloid scaling is the most common. A rare pityriasiform variety can be seen on the trunk and the neck, with peripheral scaling around ovoid patches, mimicking pityriasis rosea.

Causes:

• Malassezia organisms are probably not the cause but are a cofactor linked to a T-cell depression, increased sebum levels, and an activation of the alternative complement pathway. Persons prone to this dermatitis also may have a skin-barrier dysfunction.



• Because seborrheic dermatitis is uncommon in preadolescent children, and tinea capitis is uncommon after adolescence, dandruff in a child is more likely to represent a fungal infection. A fungal culture should be completed for confirmation.



• Various medications may flare or induce seborrheic dermatitis. These medications include auranofin, aurothioglucose, buspirone, chlorpromazine, cimetidine, ethionamide, gold, griseofulvin, haloperidol, interferon alfa, lithium, methoxsalen, methyldopa, phenothiazines, psoralens, stanozolol, thiothixene, and trioxsalen.

DIFFERENTIALS

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Asteatotic Eczema
Atopic Dermatitis
Candidiasis, Cutaneous
Contact Dermatitis, Allergic
Contact Dermatitis, Irritant
Dermatologic Manifestations of Gastrointestinal Disease
Dermatomyositis
Drug Eruptions
Drug-Induced Photosensitivity
Erythrasma
Extramammary Paget Disease
Glucagonoma Syndrome
Impetigo
Intertrigo
Lichen Simplex Chronicus
Lupus Erythematosus, Acute
Nummular Dermatitis
Pemphigus Erythematosus
Pemphigus Foliaceus
Perioral Dermatitis
Pityriasis Rosea
Rosacea
Tinea Capitis
Tinea Corporis
Tinea Cruris
Tinea Versicolor

Other Problems to be Considered:

Xerotic eczema
Chronic granulomatous disease
Exfoliative erythroderma
Facial chapping
Infectious eczematoid dermatitis
Letterer-Siwe disease
Scaling drug eruptions
Sebopsoriasis
Staphylococcal blepharitis
Tinea amiantacea
Vitamin B and/or zinc deficiency

WORKUP

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Lab Studies:

• A clinical diagnosis of seborrheic dermatitis is usually made based on a history of waxing and waning severity and by the distribution of involvement upon examination.

Procedures:

• A skin biopsy may be needed in persons with exfoliative erythroderma, and a fungal culture can be used to rule out tinea capitis.

TREATMENT

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Medical Care: Early treatment of flares is encouraged. Behavior modification techniques in reducing excoriations are especially helpful with scalp involvement.

• Topical corticosteroids may hasten recurrences, may foster dependence because of a rebound effect, and are discouraged except for short-term use. Skin involvement responds to ketoconazole, naftifine, or ciclopirox creams and gels. Alternatives include calcineurin inhibitors (ie, pimecrolimus, tacrolimus), sulfur or sulfonamide combinations, or propylene glycol. Class IV or lower corticosteroid creams, lotions, or solutions can be used for acute flares. Systemic ketoconazole or fluconazole may help if seborrheic dermatitis is severe or unresponsive.



• Dandruff responds to more frequent shampooing or a longer period of lathering. Use of hair spray or hair pomades should be stopped. Shampoos containing salicylic acid, tar, selenium, sulfur, or zinc are effective and may be used in an alternating schedule. Overnight occlusion of tar, bath oil, or Baker's P&S solution may help to soften thick scalp plaques. Derma-Smoothe F/S oil is especially helpful when widespread scalp plaques are present. Selenium sulfide (2.5%), ketoconazole, and ciclopirox shampoos may help by reducing Malassezia yeast scalp reservoirs. Shampoos may be used on truncal lesions or in beards but may cause inflammation in the intertriginous or facial areas.



• Seborrheic blepharitis may respond to gentle cleaning of eyelashes with baby shampoo and cotton applicators. The use of ketoconazole cream in this anatomical region is controversial.

MEDICATION

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The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Drug Category: Antifungals -- Mechanism of action may involve alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to fungal cells.

Drug Name	Ketoconazole creams and shampoos (Nizoral) -- Imidazole broad-spectrum antifungal agent. Inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.
Adult Dose	Rub gently into affected area qd/bid for 2-4 wk
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	If sensitivity or irritation develops, discontinue use; for external use only; avoid contact with eyes

Drug Category: Corticosteroids -- Have anti-inflammatory properties and cause profound and varied metabolic effects. Also modify body's immune response to diverse stimuli.

Drug Name	Betamethasone valerate 0.1% (Valisone) solution or lotion -- Medium-strength topical corticosteroid for body areas. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Affects production of lymphokines and has inhibitory effect on Langerhans cells.
Adult Dose	Apply to affected areas qd/bid; solutions and lotions tend to be thin and good for scalp application
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity; viral or fungal skin infections
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	May suppress adrenal function in prolonged therapy over large body surface areas; if infection present, discontinue use until under control

Drug Name	Desonide cream 0.05% -- For inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult Dose	Apply thin film qd/bid
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity; viral or fungal skin infections
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	May suppress adrenal function in prolonged therapy over large body surface areas; if infection present, discontinue use until under control

Drug Category: Keratolytics -- Cause cornified epithelium to swell, soften, macerate, and then desquamate.

Drug Name	Coal tar (DHS Tar, MG217, Theraplex T, Psoriasin) -- Inhibits deregulated epidermal proliferation and dermal infiltration; antipruritic and antibacterial.
Adult Dose	Rub copious amounts of shampoo into wet hair and scalp or skin and rinse thoroughly; repeat, leave on for 5 min and rinse thoroughly.
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity; acute inflammation or open lesions
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Do not apply to eyes; if irritation or unsatisfactory response occurs, discontinue use

Drug Category: Immunosuppressants -- Exert anti-inflammatory affect by inhibiting T-lymphocyte activation. Safer than topical steroids for prolonged use or in skin folds.

Drug Name	Tacrolimus (Protopic) ointment 0.03% and 0.1% -- Nonsteroidal anti-inflammatory agent. Should not cause steroid-type skin atrophy. Currently indicated only for atopic dermatitis in immunocompetent patients >2 y.
Adult Dose	0.1% ointment: Apply to affected areas bid for 2-6 wk
Pediatric Dose	0.03% ointment: Apply as in adults
Contraindications	Documented hypersensitivity; ointments can lead to maceration in skin folds, use with caution; not recommended in immunocompromised persons
Interactions	None reported; use with caution if using oral treatments with CYP3A4 inhibitors
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Use may aggravate superficial bacterial, fungal, or viral infections; monitor for localized lymphadenopathy; local reactions include itching or burning sensation of short duration first 1-3 d of use

Drug Name	Pimecrolimus (Elidel cream 1%) -- Nonsteroidal anti-inflammatory agent. Should not cause steroid-type skin atrophy. Currently indicated only for atopic dermatitis in immunocompetent patients >2 y. Use cream sparingly to avoid maceration in skin folds.
Adult Dose	Apply to affected areas bid for 2-6 wk
Pediatric Dose	<2 years: Not recommended >2 years: Apply as in adults
Contraindications	Documented hypersensitivity; not indicated in immunocompromised patients; efficacy and safety in geriatric patients not tested
Interactions	None reported; use with caution if using oral treatments with CYP3A4 inhibitors
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Discontinue if sensitivity or chemical irritation occurs; for external use only; may aggravate superficial bacterial, fungal, or viral infections; monitor for localized lymphadenopathy; local reactions include itching or burning sensation of short duration first 1-3 d of use

MISCELLANEOUS

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Special Concerns:

• A severe, explosive onset of seborrheic dermatitis may be a marker for HIV infection, regardless of age. It may appear as a butterfly rash, similar to the acute facial eruption associated with systemic lupus erythematosus. The dermatitis appears early in persons with AIDS, affects 25-50% of persons with AIDS, and has greater involvement and greater activity in those with diminished T-cell function. The dermatitis may be treated with topical preparations, but if severe, treatment with 400 mg of oral ketoconazole daily for 2 weeks may be necessary.



• Letterer-Siwe disease in infants may manifest as a scaling scalp and purpura.

TEST QUESTIONS

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CME Question 1: Which of the following medications is used to treat seborrheic dermatitis?

A: Cimetidine
B: Griseofulvin
C: Lithium
D: Ketoconazole
E: Tetracycline

The correct answer is D: Ketoconazole is used to treat seborrheic dermatitis. It is an imidazole, broad-spectrum, antifungal agent that inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.

CME Question 2: Seborrheic dermatitis typically does not occur on which of the following surfaces?

A: Eyelash line
B: Central part of the chest
C: Knees
D: Perineum
E: Ears

The correct answer is C: Seborrheic dermatitis does not occur on the knees. Distribution follows the oily and hair-bearing areas of the head and the neck, such as the scalp, the forehead, the eyebrows, the lash line, the nasolabial folds, the beard, and the postauricular skin. An extension to submental skin can occur. Presternal or interscapular involvement is more common than nonscaling intertrigo of the umbilicus, axillae, inframammary and inguinal folds, perineum, or anogenital crease, which also may be present.

Pearl Question 1 (T/F): Seborrheic dermatitis is more common in patients with Parkinson disease or AIDS than in other patients.

The correct answer is True: Seborrheic dermatitis may worsen in Parkinson disease and in AIDS. Seborrheic dermatitis is a papulosquamous disorder patterned on the sebum-rich areas of the scalp, the face, and the trunk. In addition to sebum, this dermatitis is linked to Malassezia, immunologic abnormalities, and activation of complement. It is commonly aggravated by changes in humidity, changes in seasons, trauma (eg, scratching), or emotional stress. The severity varies from mild dandruff to exfoliative erythroderma.

Pearl Question 2 (T/F): Dandruff in a 7-year-old child is most likely seborrheic dermatitis.

The correct answer is False: A 7-year-old child with dandruff would most likely have tinea capitis. Because seborrheic dermatitis is uncommon in preadolescent children and tinea capitis is uncommon after adolescence, dandruff in a child is more likely to represent a fungal infection. A fungal culture should be performed for confirmation.

Pearl Question 3 (T/F): The skin yeast involved in seborrheic dermatitis is Malassezia.

The correct answer is True: Seborrheic dermatitis is associated with normal levels of Malassezia but an abnormal immune response. Helper T cells, phytohemagglutinin and concanavalin stimulation, and antibody titers are depressed compared with those from control subjects. The contribution of Malassezia may come from its lipase activity—releasing inflammatory free fatty acids—and from its ability to activate the alternative complement pathway.

Pearl Question 4 (T/F): A 35-year-old man presents with an explosive onset of dandruff and facial scaling. His T-cell function is most likely higher than normal.

The correct answer is False: His T-cell function is most likely lower than normal.

PICTURES

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Caption: Picture 1. Seborrheic dermatitis affecting the scalp line and the eyebrows with red skin and scaling. Courtesy of Wilford Hall Medical Center Dermatology slide files.
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Caption: Picture 2. Seborrheic dermatitis may affect any hair-bearing area, and the chest is frequently involved. Courtesy of Wilford Hall Medical Center Dermatology Teaching slides.
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Caption: Picture 3. African Americans and persons from other darker-skinned races are susceptible to annular seborrheic dermatitis, also called petaloid seborrheic dermatitis or seborrhea petaloides. Sarcoidosis, secondary syphilis, and even discoid lupus may be in the differential in such cases. Courtesy of Jeffrey J. Meffert, MD.
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BIBLIOGRAPHY

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• Belew PW, Rosenberg EW, Jennings BR: Activation of the alternative pathway of complement by Malassezia ovalis (Pityrosporum ovale). Mycopathologia 1980 Mar 31; 70(3): 187-91[Medline].
• Carr MM, Pryce DM, Ive FA: Treatment of seborrhoeic dermatitis with ketoconazole: I. Response of seborrhoeic dermatitis of the scalp to topical ketoconazole. Br J Dermatol 1987 Feb; 116(2): 213-6[Medline].
• Cunha PR: Pimecrolimus cream 1% is effective in seborrhoeic dermatitis refractory to treatment with topical corticosteroids. Acta Derm Venereol 2006; 86(1): 69-70[Medline].
• Elish D, Silverberg NB: Infantile seborrheic dermatitis. Cutis 2006 May; 77(5): 297-300[Medline].
• Faergemann J: Severe seborrheic dermatitis. J Int Postgrad Med 1990; 2: 18-20.
• Firooz A, Solhpour A, Gorouhi F, et al: Pimecrolimus cream, 1%, vs hydrocortisone acetate cream, 1%, in the treatment of facial seborrheic dermatitis: a randomized, investigator-blind, clinical trial. Arch Dermatol 2006 Aug; 142(8): 1066-7[Medline].
• Ford GP, Farr PM, Ive FA, Shuster S: The response of seborrhoeic dermatitis to ketoconazole. Br J Dermatol 1984 Nov; 111(5): 603-7[Medline].
• Green CA, Farr PM, Shuster S: Treatment of seborrhoeic dermatitis with ketoconazole: II. Response of seborrhoeic dermatitis of the face, scalp and trunk to topical ketoconazole. Br J Dermatol 1987 Feb; 116(2): 217-21[Medline].
• Groisser D, Bottone EJ, Lebwohl M: Association of Pityrosporum orbiculare (Malassezia furfur) with seborrheic dermatitis in patients with acquired immunodeficiency syndrome (AIDS). J Am Acad Dermatol 1989 May; 20(5 Pt 1): 770-3[Medline].
• High WA, Pandya AG: Pilot trial of 1% pimecrolimus cream in the treatment of seborrheic dermatitis in African American adults with associated hypopigmentation. J Am Acad Dermatol 2006 Jun; 54(6): 1083-8[Medline].
• Jacobs PH: Seborrheic dermatitis: causes and management. Cutis 1988; 41: 182-6.
• Kligman AM, Marples RR, Lantis LR, McGinley KJ: Appraisal of efficacy of antidandruff formulations. J Soc Cosmet Chem 1974; 225: 73-91.
• Leyden JJ, McGinley KJ, Kligman AM: Role of microorganisms in dandruff. Arch Dermatol 1976 Mar; 112(3): 333-8[Medline].
• Leyden JJ, Kligman AM: Dandruff: cause and treatment. Cosmetics & Toiletries 1979; 94: 23-28.
• Leyden JJ: Overview: Pityrosporum and scaling disorders of the scalp. J Int Postgrad Med 1990; 2: 5-9.
• Litt JZ, Powlak WA: Drug Eruption Reference Manual. 5th ed. Cleveland, Ohio; Wal-Zac Enterprises; 1966: 465.
• Odom RB: Seborrheic dermatitis in AIDS. J Int Postgrad Med 1990; 2: 18-20.
• Pontasch MJ, Kyanko ME, Brodell RT: Tinea versicolor of the face in black children in a temperate region. Cutis 1989 Jan; 43(1): 81-4[Medline].
• Schwartz RA, Janusz CA, Janniger CK: Seborrheic dermatitis: an overview. Am Fam Physician 2006 Jul 1; 74(1): 125-30[Medline].
• Shuster S: The aetiology of dandruff and the mode of action of therapeutic agents. Br J Dermatol 1984 Aug; 111(2): 235-42[Medline].
• Siadat AH, Iraji F, Shahmoradi Z, et al: The efficacy of 1% metronidazole gel in facial seborrheic dermatitis: a double blind study. Indian J Dermatol Venereol Leprol 2006 Jul-Aug; 72(4): 266-9[Medline].
• Skinner RB Jr, Noah PW, Taylor RM, et al: Double-blind treatment of seborrheic dermatitis with 2% ketoconazole cream. J Am Acad Dermatol 1985 May; 12(5 Pt 1): 852-6[Medline].
• Weary PE: Pityrosporum ovale: observation on some aspects of host-parasite interrelationship. Arch Dermatol 1968; 98: 408.
• Zisova LG: Fluconazole and its place in the treatment of seborrheic dermatitis--new therapeutic possibilities. Folia Med (Plovdiv) 2006; 48(1): 39-45[Medline].

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