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Treatment of Seborrheic Dermatitis

BETTY ANNE JOHNSON, M.D., PH.D., and
JULIA R. NUNLEY, M.D.
Medical College of Virginia Campus of Virginia Commonwealth
University, Richmond, Virginia

A patient information
handout on seborrheic
dermatitis, written by the
authors of this article, is
provided on page 2713.

Seborrheic dermatitis is a chronic inflammatory disorder affecting areas of the head and trunk where
sebaceous glands are most prominent. Lipophilic yeasts of the Malassezia genus, as well as genetic,
environmental and general health factors, contribute to this disorder. Scalp seborrhea varies from mild dandruff
to dense, diffuse, adherent scale. Facial and trunk seborrhea is characterized by powdery or greasy scale in
skin folds and along hair margins. Treatment options include application of selenium sulfide, pyrithione zinc or
ketoconazole-containing shampoos, topical ketoconazole cream or terbinafine solution, topical sodium
sulfacetamide and topical corticosteroids. (Am Fam Physician 2000;61:2703-10,2713-4.)

The etiology of seborrheic dermatitis remains unknown, although many factors, including hormonal,
have been implicated. This chronic inflammatory skin disorder is generally confined to areas of the
head and trunk where sebaceous glands are most prominent. When seborrheic dermatitis occurs in the
neonatal period, it usually disappears by six to 12 months of age, suggesting that it may be a response
to maternal hormone stimulation.1
Seborrheic dermatitis frequently affects persons in
postpuberty. Additional evidence of hormonal influence is Seborrheic dermatitis is a chronic
provided by research demonstrating that the human sebocyte inflammatory
skin
disorder
responds to androgen stimulation.2
generally confined to areas
where sebaceous glands are
Pityrosporum ovale, a lipophilic yeast of the Malassezia
prominent.
genus, has been implicated in the development of this
condition.3 It has been suggested that seborrheic dermatitis
is an inflammatory response to this organism, but this remains to be proved.4 P. ovale is present on all
persons. Why some persons develop seborrheic dermatitis and others do not is unclear. The
colonization rate of involved skin by this organism may be lower than that of uninvolved skin.3
Nonetheless, the fact that seborrheic dermatitis responds to antifungal medications is strongly
suggestive of the role of yeast in this disorder.
Genetic and environmental factors, as well as other
comorbid diseases, may predispose specific populations to Although specific details remain
the development of seborrheic dermatitis. Although unknown, Pityrosporum ovale is
seborrheic dermatitis affects only 3 percent of the general
strongly suspected to play a role
population, the incidence in persons with acquired
in the manifestation of seborrheic
immunodeficiency syndrome may be as high as 85 percent.
dermatitis.
The exact mechanism whereby human immunodeficiency
virus infection promotes an atypical and explosive onset of
seborrheic dermatitis (and other common inflammatory skin disorders) is unknown, but many factors
have been explored, including CD4-positive T lymphocyte counts,5 P. ovale density6 and nutritional
factors.7

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Persons with central nervous system disorders (Parkinson's disease, cranial nerve palsies, major
truncal paralyses) also appear to be prone to the development of seborrheic dermatitis, tend to develop
more extensive disease and are frequently refractory to treatment. It has been postulated that
seborrheic dermatitis in these patients is a result of increased pooling of sebum caused by immobility.
This increased sebum pool permits growth of P. ovale, which induces seborrheic dermatitis.8

FIGURE 1. Seborrheic
dermatitis of the scalp.

FIGURE 2.
dermatitis of
margin.

Seborrheic
the scalp

FIGURE 3. Seborrheic
dermatitis of the forehead.

Clinical manifestations of seborrheic dermatitis

Seborrheic dermatitis typically affects areas of the skin where sebaceous glands appear in high
frequency and are most active. The distribution is classically symmetric, and common sites of
involvement are the hairy areas of the head, including the scalp (Figure 1), the scalp margin (Figure
2), eyebrows, eyelashes, mustache and beard. Other common sites are the forehead (Figure 3), the
nasolabial folds (Figure 4), the external ear canals (Figure 5) and the postauricular creases. Seborrhea
of the trunk may appear in the presternal area (Figure 6) and in the body folds, including the axillae,
navel, groin, and in the inframammary and anogenital areas. Figure 7 illustrates the typically
symmetric distribution of seborrheic dermatitis.

FIGURE 4. Seborrheic
dermatitis of the nasolabial
folds.

FIGURE 5. Seborrheic
dermatitis of the external
ear canal.

FIGURE 6. Seborrheic
dermatitis of the presternal
area of the chest.

One of the characteristics of seborrheic dermatitis is dandruff, characterized by a fine, powdery white
scale on the scalp. Many patients complain of the scalp itching with dandruff, and because they think
that the scale arises from dry skin, they decrease the frequency of shampooing, which allows further
scale accumulation. Inflammation then occurs and their symptoms worsen.
More
severe
seborrheic
dermatitis
is
characterized
by
erythematous
plaques
frequently associated with powdery or greasy
scale in the scalp (Figure 8), behind the ears
(Figure 9) and elsewhere in the distribution
described above. Besides an itchy scalp, patients
may complain of a burning sensation in facial
areas affected by seborrhea. Seborrhea frequently

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becomes apparent when men grow mustaches or

beards and disappears when the facial hair is
removed. If left untreated, the scale may become
thick, yellow and greasy and, occasionally,
secondary bacterial infection may occur.
Seborrheic dermatitis is more common in men
than in women, probably because sebaceous
gland activity is under androgen control.
Seborrhea usually first appears in persons in their
teens and twenties and generally follows a
waxing/waning course throughout adulthood.
UV-A and UV-B light inhibit the growth of P.
ovale,9 and many patients report improvement in
seborrhea during summer.

Treatment
General Treatment Overview
Hygiene issues play a key role in controlling
seborrheic dermatitis. Frequent cleansing with
soap removes oils from affected areas and
improves seborrhea. Patients should be
counseled that good hygiene must be a lifelong
commitment. Outdoor recreation, especially
during summer, will also improve seborrhea,
although caution should be taken to avoid sun
damage.
Pharmacologic treatment options for seborrheic
dermatitis include antifungal preparations
(selenium sulfide, pyrithione zinc, azole agents,
sodium sulfacetamide and topical terbinafine)
that decrease colonization by lipophilic yeast and
anti-inflammatory agents (topical steroids).
Suggested products are listed in Table 1. For FIGURE 7. Typical symmetrical distribution of
severe disease, keratolytics such as salicylic acid seborrheic dermatitis on the head (top), and on the
or coal tar preparations may be used to remove body (bottom).
dense scale; then topical steroids may be applied.
Other options for removing adherent scale involve applying any of a variety of oils (peanut, olive or
mineral) to soften the scale overnight, followed by use of a detergent or coal tar shampoo.
As a last resort in refractory disease, sebosuppressive agents such as isotretinoin (Accutane) may be
used to reduce sebaceous gland activity.
Treatment of Scalp and Beard Areas
Many cases of seborrheic dermatitis are effectively treated by shampooing daily or every other day
with antidandruff shampoos containing 2.5 percent selenium sulfide or 1 to 2 percent pyrithione zinc.
Alternatively, ketoconazole shampoo may be used.10 The shampoo should be applied to the scalp and
beard areas and left in place for five to 10 minutes before rinsing. A moisturizing shampoo may be
used afterward to prevent dessication of the hair. After the disease is under control, the frequency of
shampooing with medicated shampoos may be decreased to twice weekly or as needed. Topical
terbinafine solution, 1 percent, has also been shown to be effective in the treatment of scalp

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seborrhea.11
If the scalp is covered with diffuse, dense scale, the scale may first be removed by applying warm
mineral oil or olive oil to the scalp and washing several hours later with a detergent such as a
dishwashing liquid or a tar shampoo.12 An alternative is an overnight application of a coal tarkeratolytic combination or phenol-saline solution with or without occlusion with a plastic shower cap
followed by shampooing in the morning.13

FIGURE 8. Severe seborrheic

dermatitis
of
the
scalp
manifested by plaques of dense
scale.

FIGURE
9.
Seborrheic
dermatitis behind the ear,
manifested by a plaque of scale.

Extensive scale with associated inflammation may be treated by moistening the scalp and then
applying fluocinolone acetonide, 0.01 percent in oil, to the entire scalp, covering overnight with a
shower cap and shampooing in the morning. This treatment may be done nightly until the
inflammation clears and then decreased to one to three times weekly as needed. Topical corticosteroid
solutions, lotions or ointments may be used once or twice daily for one to three weeks in place of the
overnight application of fluocinolone acetonide and may be stopped when itching and erythema
disappear. Corticosteroid application may be repeated daily for one to three weeks until itching and
erythema disappear, and then used as needed. Maintenance with an antidandruff shampoo may then
be adequate. Patients should be advised to use potent topical steroids sparingly because excessive use
may lead to atrophy of the skin and telangiectasis.
Infants frequently have seborrheic dermatitis, commonly known as "cradle cap." Areas of possible
involvement include the scalp, face and intertriginous areas. Involvement may be extensive, but this
disorder frequently clears spontaneously by six to 12 months of age and does not recur until the onset
of puberty.
A scaly scalp in a prepubertal child is usually caused by tinea capitis, not seborrheic dermatitis.
Therapy for infantile seborrheic dermatitis includes frequent shampooing with an antidandruff
shampoo. If scale is extensive in the scalp, the scale may be softened with oil, gently brushed free
with a baby hairbrush and then washed clear.
Daily shampooing may not be reasonable for some populations, such as black persons or persons who
are institutionalized. In general, weekly shampooing is recommended for black persons. As a
substitute for daily washing, fluocinolone acetonide, 0.01 percent in oil, may be used as a scalp
pomade. Other options include application of a moderate- to mid-potency topical corticosteroid in an
ointment base. As with other modes of therapy, these agents are used every day or twice daily until
the condition improves. Thereafter, topical corticosteroids are used as needed to keep the condition
under control. After initial control is attained, fluocinolone acetonide, 0.01 percent shampoo (FS
Shampoo), can be used as an alternative to or in addition to fluocinolone acetonide, 0.01 percent in oil
(Derma-Smoothe/FS), for maintenance.

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TABLE 1
Treatment of Seborrheic Dermatitis
Overthecounter? Scalp Beard Face Body Instructions

Products

Cost*

Shampoos
Selenium sulfide, Yes
1%
(Selsun Blue)

5to
10-minute $3 per 120 mL
application
daily bottle
initially; then twice
weekly as needed

Selenium sulfide, No
2.5%
(Exsel, Selsun)

Same as above

15 per 120 mL
(Exsel)
12 per 120 mL
(Selsun)

Pyrithione
zinc, Yes
1%
(Dandrex, Zincon,
Head
and
Shoulders)

Same as above

5 per 240
(Dandrex)
3 per 120
(Zincon)
3 per 450
(Head
Shoulders)

Pyrithione
zinc, Yes
2%
(DHS
Zinc,
Sebulon, ZNP Bar,
Theraplex Z)

Coal tar
Crude coal tar:

Same as above

mL
mL
mL
and

7 per 240 mL
(DHS Zinc)
11 per 240 mL
(Sebulon)
6 per 135 g
(ZNP Bar)
7 per 240 mL
(Theraplex Z)

May be irritating,
especially on the face
5to
10-minute
application
daily
initially,
then
as 5 per 120 mL
(DHS
Tar
needed
0.5%)

DHS Tar (0.5%) Yes

Yes

14 per 180 mL
(Zetar 1%)

Plus Yes

12 per 240 mL
(Ionil T Plus
2%)

Zetar (1%)
Ionil
(2%)

Coal
combinations:

tar

Sebutone
Yes
(0.5%
with
salicylic acid, 2%,
and
sublimed
sulfur, 2%)

Same as above

Coal tar distillate:

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10 per 210 mL
(Sebutone)

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Doak-Tar (3%)

Yes

Same as above

7 per 60 mL
(Doak-Tar)

Yes

Same as above

4 per 132 mL
(Neutrogena
T/Gel)

Tegrin Dandruff Yes

(7%)

5 per 210 mL
(Tegrin
Dandruff)

(7.71 Yes

7 per 120 mL
(Pentrax)

Yes

Denorex Extra Yes

Strength (12.5%)

Ionil T
Yes
(5% with salicylic
acid, 2%)

X-Seb T Plus
Yes
(10% with salicylic
acid, 3%)

12 per 120 mL
(X-Seb T Plus)

Tarsum
Yes
(10% with salicylic
acid, 2%)

7 per 120 mL
(Tarsum)

Chloroxine
Capitrol, 2%

Coal tar extract:

Neutrogena
T/Gel (2%)

Pentrax
%)
Coal tar
solution:

topical

Denorex
Medicated (9%)

Same as above

4 per 120 mL
(Denorex
Medicated)
4 per 120 mL
(Denorex Extra
Strength)

Coal tar solution

combinations

No

8 per 120 mL
(Ionil T)

3-minute application 20 per 120 mL

twice weekly

Ketoconazole
Nizoral, 1%

Yes

Nizoral, 2%

No

No

Yes

Steroid shampoo
FS Shampoo
(0.01%
fluocinolone
acetonide)

Same as above

5to
10-minute
application to scalp
before rinsing clear; 7 per 120 mL
use daily initially, (Nizoral 1%)
then twice weekly
21 per 120 mL
(Nizoral 2%)

5to
10-minute 15 per 120 mL
application to scalp
before rinsing clear;
use daily initially until
inflammation clears,
then as needed

Apply once or twice

daily
until
inflammation clears, 3 per 15 g
(Cortaid, 1%)
then as needed
3 per 15 g

Topical
Preparations
Corticosteroids
Cortaid,
1%;
Cortizone 10
(hydrocortisone

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cream, 1%)
Tridesilon
(desonide, 0.5%)

No

Hytone
(hydrocortisone
cream, 2.5%)

No

DermaNo
smoothe/FS
Topical oil
(fluocinolone
acetonide, 0.01%
in oil)

For
scalp
preparations, apply to
scalp nightly until
inflammation clears,
then 1 to 3 times
weekly as needed

Antifungals

(Cortizone 10)
12 per 15 g
(Tridesilon)
25 per 30 g
(Hytone)
18 per 120 mL
(Dermasmoothe/GS
Topical oil)

Apply once or twice 5 per 15

daily
(Micatin)

Miconazole
cream, 2%
(Monistat)

Yes

Clotrimazole
cream, 1%
(Lotrimin)

Yes

6 per 12
(Lotrimin)

Terbinafine
solution, 1%
(Lamisil)

Yes

33 per 15 g
(Lamisil)

Ketoconazole
cream, 2%
(Nizoral)

No

17 per 15 g
(Nizoral)

24 per 85 g
(Sebizon)

Other preparations
Sodium
sulfacetamide
Sebizon
(10% lotion)

No

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