Seborrhoeic dermatitis – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

Chronic, superficial, recurrent inflammatory rash affecting sebum-rich, hairy regions of the body, especially scalp, eyebrows, and face

Epidemiology

Incidence

  • Predominant age: Infancy, adolescence, and adulthood
  • Predominant sex: Male > Female

Prevalence

Seborrheic dermatitis: 3–5%

Risk Factors

  • Parkinson disease
  • AIDS (disease severity correlated with progression of immune deficiency)
  • Emotional stress
  • Medications may flare or induce seborrheic dermatitis: Auranofin, aurothioglucose, buspirone, chlorpromazine, cimetidine, ethionamide, gold, griseofulvin, haloperidol, interferon alfa, lithium, methoxsalen, methyldopa, phenothiazine, psoralen, stanozolol, thiothixene, trioxsalen

Genetics

Positive family history; no genetic marker identified to date

General Prevention

Seborrheic skin should be washed more often than usual.

Pathophysiology

Helper T cells, phytohemagglutinin and concanavalin stimulation, and antibody titers are depressed compared with those of control subjects.

Etiology

  • Skin surface yeasts Malassezia (formerly P. ovale) may be a contributing factor (1).
  • Malassezia spp. may have a role in T-cell suppression and complement activation.
  • The mite D. folliculorum may have a direct or indirect role.
  • Genetic and environmental factors: Flares are common with stress or illness.
  • Parallels increased sebaceous gland activity in infancy and adolescence or as a result of some acnegenic drugs

Commonly Associated Conditions

  • Parkinson disease
  • AIDS

Seborrhoeic dermatitis, Parkinson's disease, Cradle cap, Hyperkeratotic hand dermatitis, antibody titers, interferon alfa, emotional stress, phenothiazine,

Diagnosis

The diagnosis of seborrheic dermatitis usually can be made by history and physical examination.

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.
  • Infants:
    • Cradle cap: Greasy scaling of scalp, sometimes with associated mild erythema
    • Diaper and/or axillary rash
    • Age at onset typically ∼1 month
    • Usually resolves by 8–12 months
  • Adults:
    • Red, greasy, scaling rash in most locations consisting of patches and plaques with indistinct margins
    • Red, smooth, glazed appearance in skin folds
    • Minimal pruritus
    • Chronic waxing and waning course
    • Bilateral and symmetric
    • Most commonly located in hairy skin areas: Scalp and scalp margins, eyebrows and eyelid margins, nasolabial folds, ears and retroauricular folds, presternal area, and middle to upper back, buttock crease, inguinal area, genitals, and armpits

Physical Exam

  • Scalp appearance varies from mild, patchy scaling to widespread, thick, adherent crusts. Plaques are rare.
  • 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.
  • Seborrheic blepharitis may occur independently.

Diagnostic Tests & Interpretation

Diagnostic Procedures/Surgery

Consider biopsy if:

  • Usual therapies fail
  • Petechiae noted
  • Histiocytosis X suspected
  • Fungal cultures in refractory cases or when pustules and alopecia are present

Pathological Findings

Nonspecific changes:

  • Hyperkeratosis, acanthosis, accentuated rete ridges, focal spongiosis, and parakeratosis are characteristic.
  • Parakeratotic scale around hair follicles and mild superficial inflammatory lymphocytic infiltrate

Differential Diagnosis

  • Atopic dermatitis: Distinction may be difficult in infants.
  • Psoriasis:
    • Usually knees, elbows, and nails are involved.
    • Scalp psoriasis will be more sharply demarcated than seborrhea, with crusted, infiltrated plaques rather than mild scaling and erythema.
  • Candida
  • Tinea cruris or capitis: Suspect these when usual medications fail or if hair loss occurs.
  • Eczema of auricle or otitis externa
  • Rosacea
  • Discoid lupus erythematosus: Skin biopsy will be beneficial.
  • Histiocytosis X: May appear as seborrheic-type eruption
  • Dandruff: Scalp only, noninflammatory

Treatment

Medication

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First Line

  • Cradle cap: Use a coal tar shampoo or ketoconazole (Nizoral) shampoo if the nonmedicated shampoo is ineffective (2).
  • Adults:
    • Topical antifungal agents:
      • Ketoconazole 2% foam or shampoo twice a week for clearance, then once a week or every other week for maintenance
      • Ketoconazole (Nizoral) cream may be used to clear scales in other areas.
      • Ciclopirox 1% shampoo twice weekly (1)[B]
    • Topical corticosteroids:
      • Begin with 1% hydrocortisone, and advance to more potent (fluorinated) steroid preparations as needed.
      • Avoid continuous use of the more potent steroids to reduce the risk of skin atrophy, hypopigmentation, or systemic absorption (especially in infants and children).
      • Precautions: Fluorinated corticosteroids and higher concentrations of hydrocortisone (e.g., 2.5%) may cause atrophy or striae if used on the face or on skin folds.
    • Other topical agents:
      • Coal tar1% shampoo twice a week
      • Selenium sulfide 2.5% shampoo twice a week
      • Zinc pyrithione shampoo twice a week
      • Lithium succinate ointment twice a week
  • Once controlled, washing with zinc soaps or selenium lotion with periodic use of steroid cream may help to maintain remission.

Second Line

  • Calcineurin inhibitors:
    • Pimercolimus 1% cream twice daily
    • Tacrolimus 0.1% ointment twice daily
  • Systemic antifungal therapy:
    • Data are limited.
    • For moderate to severe seborrheic dermatitis:
      • Ketoconazole 200 mg/d
      • Itraconazole 200 mg/d
      • Daily regimen for 1–2 months followed by twice-weekly dosing for chronic treatment
      • Monitor potential hepatotoxic effects.

Additional Treatment

General Measures

  • Increase frequency of shampooing.
  • Sunlight in moderate doses may be helpful.
  • Cradle cap:
    • Frequent shampooing with a mild, nonmedicated shampoo
    • Remove thick scale by applying warm mineral oil, and then wash off an hour later with a mild soap and a soft-bristle toothbrush or terrycloth washcloth (2).
  • Adults: Wash all affected areas with antiseborrheic shampoos. Start with over-the-counter brands (Tegrin, Selsun Blue), and increase to more potent preparations (containing coal tar, sulfur, selenium, or salicylic acid) if no improvement is noted (2).
  • For dense scalp scaling, 10% liquor carbonic detergens in Nivea oil may be used at bedtime, covering the head with a shower cap. This should be done nightly for 1–3 weeks.

Issues for Referral

No response to 1st-line therapy and concerns regarding systemic illness (HIV, etc.)

Ongoing Care

Follow-Up Recommendations

Patient Monitoring

Every 2–12 weeks as necessary depending on disease severity and degree of patient sophistication

Patient Education

http://familydoctor.org/online/famdocen/home/common/skin/disorders/157.html

Prognosis

  • In infants, seborrheic dermatitis usually remits after 6–8 months.
  • In adults, seborrheic dermatitis is usually chronic and unpredictable, with exacerbations and remissions. Disease is usually easily controlled with shampoos and topical steroids.

Complications

  • Skin atrophy or striae are possible from fluorinated corticosteroids, especially if used on the face.
  • Glaucoma can result from use of fluorinated steroids around the eyes.
  • Photosensitivity is caused occasionally by tars.
  • Herpes keratitis is a rare complication of herpes simplex: Instruct patient to stop eyelid steroids if herpes simplex develops.

References

1. Shuster S, Meynadier J, Kerl H, et al. Treatment and prophylaxis of seborrheic dermatitis of the scalp with antipityrosporal 1% ciclopirox shampoo. Arch Dermatol. 2005;141:47–52.

2. Johnson BA, Nunley JR. Treatment of seborrheic dermatitis. Am Fam Physician. 2000;61:2703–10, 2713–4.

Additional Reading

Darabi K, Hostetler SG, Bechtel MA, et al. The role of Malassezia in atopic dermatitis affecting the head and neck of adults. J Am Acad Dermatol. 2008.

Karincaoglu Y, Tepe B, Kalayci B, et al. Is Demodex folliculorum an aetiological factor in seborrhoeic dermatitis? Clin Exp Dermatol. 2009.

Naldi L, Rebora A. Clinical practice. Seborrheic dermatitis. N Engl J Med.2009;360:387–96.

Shemer A, Kaplan B, Nathansohn N, et al. Treatment of moderate to severe facial seborrheic dermatitis with itraconazole: an open non-comparative study. Isr Med Assoc J. 2008;10:417–8.

Shin H, Kwon OS, Won CH, et al. Clinical efficacies of topical agents for the treatment of seborrheic dermatitis of the scalp: A comparative study. J Dermatol. 2009;36:131–7.

See Also (Topic, Algorithm, Electronic Media Element)

Algorithm: Rash, Focal

Codes

ICD9

  • 690.10 Seborrheic dermatitis, unspecified
  • 690.11 Seborrhea capitis
  • 690.12 Seborrheic infantile dermatitis
  • 690.18 Other seborrheic dermatitis

Snomed

  • 50563003 seborrheic dermatitis (disorder)
  • 62742006 cradle cap (disorder)
  • 200776003 infantile seborrheic dermatitis (disorder)

Clinical Pearls

Search for an underlying systemic disease in a patient who is unresponsive to usual therapy.

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