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Treatment

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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Treatment of seborrhoeic dermatitis generally involves the use of topical steroids and/or antifungals such as ketoconazole. Topical antifungal agents are the mainstay of treatment. Topical steroids are useful in the short term mainly to control erythema and itching (1)

The scalp (2)

  • ketoconazole 2% shampoo
    • initially use two to four times a week then once every two weeks for maintenance. an alternative is selenium sulphide shampoo
  • for itch and erythema - a topical steroid scalp application or mousse
  • for scale and crusts - olive oil for mild crusting. Sebco ® ointment massaged in and left on for two to four hours can be very useful for thicker scale / crust

Topical treatments for the skin (3)

  • topical ketoconazole cream - some patients find this causes too much skin irritation, in which case use either miconazole or clomitrazole cream
  • topical steroids can be added in for flare-ups but should only be used for one to two days at a time on facial skin
    • for adults who are affected by face and/or body seborrhoeic dermatitis, a mild topical corticosteroid cream, such as hydrocortisone 1% (or a combined imidazole and hydrocortisone preparation) can be considered to settle inflammation more quickly
  • if there are concerns about how much topical steroid is being used on the face consider the off-label use of topical calcineurin inhibitors eg pimecrolimus cream or tracrolimus ointment

More extensive or recalcitrant symptoms (4)

  • consider systemic itraconazole 100 mg per day for 14 days
  • if symptoms relapse frequently then consider six to eight week courses of a systemic tetracycline (off-label), which have an anti-inflammatory effect on the skin
  • consider HIV in patients with more severe symptoms (5)
  • patients responding inadequately to treatment should be referred to Secondary Care
    • in such cases a prolonged course of low dose isotretinoin, used off-label, may be considered

Ocular symptoms (6)

  • lid hygiene - clean eyelids using cotton wool soaked in cooled boiled water
  • artificial tears - should be applied liberally through the day if the eyes are dry or sore. If necessary a lubricating ointment, sometimes containing an antibiotic preparation may be used at night
  • as with rosacea, systemic tetracyclines given for six to eight weeks at a time can be useful for more troublesome symptoms such as blepharitis
    • erythromycin can be used in patients unable to take tetracyclines

Reference:

1. Kastarinen H, Oksanen T, Okokon EO, et al. Topical anti-inflammatory agents for seborrhoeic dermatitis of the face or scalp. Cochrane Database Syst Rev. 2014;(5):CD009446.

2. Schwartz JR, Bacon RA, Shah R, et al. Therapeutic efficacy of anti-dandruff shampoos: a randomized clinical trial comparing products based on potentiated zinc pyrithione and zinc pyrithione/climbazole. Int J Cosmet Sci. 2013;35:2013 Aug;35(4):381-7.

3. Apasrawirote W et al. Topical antifungal agents for seborrheic dermatitis: systematic review and meta-analysis. J Med Assoc Thai. 2011 Jun;94(6):756-60.

4. Swinyer LJ, Decroix J, Langner, A. Ketoconazole gel 2% in the treatment of moderate to severe seborrheic dermatitis. Cutis. 2007 Jun;79(6):475-82.

5. Cortes-Correa C. et al. Facial Seborrheic Dermatitis in HIV-Seropositive Patients. Clin Cosmet Investig Dermatol. 2022; 15: 483–488.

6. Seborrhoeic eczema. Management of Ocular Symptoms. Primary Care Dermatology Society. Online 2024


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