Seborrheic dermatitis: treatment

Adults: scalp

• First line: ketoconazole 2% shampoo, used twice weekly for about 4 weeks. Selenium sulfide, zinc pyrithione, ciclopirox or salicylic acid shampoos also work.
• Inflamed or thick scale: add a topical corticosteroid. Goldman-Cecil suggests fluocinolone acetonide 0.01% solution, gel or ointment twice daily for 3 to 4 weeks, then ketoconazole shampoo daily or every other day. - Goldman-Cecil Medicine, Seborrheic Dermatitis
• Maintenance: ketoconazole 2% shampoo about once weekly. Relapse is common without maintenance. Because Malassezia regrows slowly, relapses appear after an interval of weeks, so the maintenance schedule should follow that rhythm. - Dermatology 5e, Adult seborrheic dermatitis

Adults: face and body

• Mainstay: topical azoles, with response rates of 75 to 90% in double-blind trials. Ciclopirox olamine is also effective. - Dermatology 5e
• Short-term anti-inflammatory: low-potency steroids, such as hydrocortisone 2.5% twice daily for 1 to 2 weeks. A Cochrane analysis found them about as effective as azoles. Use them for short courses only, because of the risk of skin atrophy and telangiectasia on the face.
• Steroid-sparing options: topical calcineurin inhibitors (pimecrolimus, tacrolimus). These are off-label but useful for the face and for long-term use. - Dermatology 5e
• Newer option: roflumilast 0.3% foam, a topical PDE4 inhibitor, is FDA-approved for patients aged 9 and older. In a phase III trial, about 80% of patients were clear or almost clear at 8 weeks, versus 58% on vehicle. This comes from a web summary of the trial, not from the textbooks. A narrative review describes it as the first new SD drug in about 20 years and a possible future first-line agent. It is generally positioned as a second-line choice for now, partly because of cost.

Severe or refractory disease

• Short course of an oral antifungal, such as itraconazole or weekly fluconazole. Dermatology 5e reserves systemic antimycotics for severe findings or frequent recurrences.
• Low-dose isotretinoin has been used for recalcitrant cases (per the narrative review above).
• Check for HIV or Parkinson disease if SD is unusually extensive or inflammatory. Goldman-Cecil notes that SD is more common and more inflammatory in HIV infection.

Infants (cradle cap)

• Bathing, emollients and mild shampoos are usually enough. Ketoconazole 2% cream can be used for extensive or persistent cases. A brief course of low-potency steroid may be used initially. - Dermatology 5e
• Avoid strong keratolytics and forceful scale removal.

Practical points

• Combination therapy is common: an antifungal for the Malassezia, a steroid or calcineurin inhibitor for inflammation, and a keratolytic such as salicylic acid, tar or propylene glycol for thick scale.
• Ketoconazole foam and gel contain ethanol, which can dry hair.
• Avoid systemic steroids.
• Avoid harsh, alcohol-based or irritating products.

Recent evidence check