Treatment

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

• 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

• 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 (4)
• 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 (3)

More extensive or recalcitrant symptoms

• 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
• 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 (3)

Ocular symptoms

• 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 (3)
  • erythromycin can be used in patients unable to take tetracyclines (3)

Reference:

• (1) Naldi L, Rebora A. Seborrheic dermatitis. N Engl J Med.2009;360:387-396
• (2) Update (24/9/97), 338-44
• (3) Primary Care Dermatological Society. Seborrhoeic dermatitis (Accessed 30/7/14)
• (4) Clinical Knowledge Summaries (July 2008). Seborrhoeic dermatitis.