Seborrheic eczema

Published on 16/03/2015 by admin

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Seborrheic eczema

Anja K. Weidmann, Jason D.L. Williams and Ian Coulson

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Seborrheic eczema (seborrheic dermatitis) is a chronic dermatosis affecting between 3% and 10% of adults becoming more prevalent with age. It is more common in patients with both idiopathic and neuroleptic-induced Parkinson’s disease, HIV, AIDS, and chronic alcoholics and accounts for up to 3.5% of dermatology specialist outpatient consultations.

The signs and symptoms comprise erythema, greasy scaling, pruritus, burning, and dryness in a typical distribution pattern affecting the scalp, face (particularly the nasolabial folds, eyebrows, and ears), upper trunk, and flexures. Blepharoconjunctivitis may occur alone or in conjunction with skin lesions. Seborrheic eczema can also affect infants up to the age of 3–4 months in the diaper area.

Although the etiology has yet to be fully elucidated, important factors are Malassezia yeasts, immune status, and individual susceptibility.

Management strategy

Seborrheic eczema is a chronic relapsing dermatitis which responds to a variety of immunosuppressive and antifungal therapies, but there is no cure.

Seborrheic eczema of the face is dry and flaky, so soap avoidance and substitution with a light emollient cleanser will help. Facial and flexural disease responds to mild topical corticosteroids alone or in combination with a variety of topical antipityrosporal agents such as miconazole, ketoconazole, bifonazole, itraconazole or ciclopiroxolamine. An ointment containing lithium gluconate/succinate may also be helpful.

Studies have demonstrated short-term efficacy with the topical calcineurin inhibitors tacrolimus and pimecrolimus. Terbinafine cream and metronidazole gel may also be beneficial while resistant cases may respond to short courses of oral itraconazole or terbinafine.

Scalp seborrheic dermatitis can be helped with topical ketoconazole, zinc pyrithione, selenium sulfide, corticosteroids and tar shampoos, or a propylene glycol preparation formulated for scalp use. Severe cases with marked hyperkeratosis (pityriasis amiantacea) may require topical keratolytics such as salicylic acid ointment or coconut compound ointment.

Specific investigations

In neonates and children consider acrodermatitis enteropathica or transient neonatal zinc deficiency as they may mimic recalcitrant seborrheic dermatitis. A similar eruption in parenterally fed adults can occur due to zinc deficiency.

Non-scalp disease

First-line therapies

image Topical ketoconazole A
image Mild/moderate topical corticosteroids A
image Emollients and soap substitutes D

Second-line therapies

image Lithium succinate/lithium gluconate A
image Ciclopiroxolamine cream A
image Topical calcineurin inhibitors A

Third-line therapies

image Oral terbinafine A
image Oral itraconazole B
image Metronidazole gel B
image Non-steroidal cream B
image Phototherapy C
image Benzoyl peroxide B
image Topical terbinafine B

Scalp disease

First-line therapies

image Ketoconazole shampoo A
image Ciclopirox shampoo A
image Zinc pyrithione shampoo B

Second-line therapies

image Propylene glycol lotion A
image Potent/superpotent topical corticosteroids A
image Tacrolimus ointment A
image Miconazole A
image Selenium sulfide shampoo C

Efficacious and safe management of moderate to severe scalp seborrhoeic dermatitis using clobetasol propionate shampoo 0.05% combined with ketoconazole shampoo 2%: a randomized, controlled study.

Ortonne JP, Nikkels AF, Reich K, Ponce Olivera RM, Lee JH, Kerrouche N, et al. Br J Dermatol 2011; 165: 171–6.

This investigator-blind randomized control trial had four treatment regimens: ketoconazole 2% shampoo twice weekly, clobetasol propionate 0.05% shampoo twice weekly, alternating ketoconazole and clobetasol twice weekly, or ketoconazole four times weekly alternating with clobetasol twice weekly for 4 weeks. This was followed by a 4-week maintenance phase where all patients received weekly ketoconazole and a further 4-week follow-up phase. In total 326 patients were included. All groups demonstrated clinical improvement and all three clobetasol-containing regimens were significantly more effective than ketoconazole alone. Of these the twice weekly alternating clobetasol and ketoconazole regimen was the most effective.

The authors would like to stress that potent and superpotent steroid may not be considered suitable for long-term use.

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Seborrheic eczema

Anja K. Weidmann, Jason D.L. Williams and Ian Coulson

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Seborrheic eczema (seborrheic dermatitis) is a chronic dermatosis affecting between 3% and 10% of adults becoming more prevalent with age. It is more common in patients with both idiopathic and neuroleptic-induced Parkinson’s disease, HIV, AIDS, and chronic alcoholics and accounts for up to 3.5% of dermatology specialist outpatient consultations.

The signs and symptoms comprise erythema, greasy scaling, pruritus, burning, and dryness in a typical distribution pattern affecting the scalp, face (particularly the nasolabial folds, eyebrows, and ears), upper trunk, and flexures. Blepharoconjunctivitis may occur alone or in conjunction with skin lesions. Seborrheic eczema can also affect infants up to the age of 3–4 months in the diaper area.

Although the etiology has yet to be fully elucidated, important factors are Malassezia yeasts, immune status, and individual susceptibility.

Management strategy

Seborrheic eczema is a chronic relapsing dermatitis which responds to a variety of immunosuppressive and antifungal therapies, but there is no cure.

Seborrheic eczema of the face is dry and flaky, so soap avoidance and substitution with a light emollient cleanser will help. Facial and flexural disease responds to mild topical corticosteroids alone or in combination with a variety of topical antipityrosporal agents such as miconazole, ketoconazole, bifonazole, itraconazole or ciclopiroxolamine. An ointment containing lithium gluconate/succinate may also be helpful.

Studies have demonstrated short-term efficacy with the topical calcineurin inhibitors tacrolimus and pimecrolimus. Terbinafine cream and metronidazole gel may also be beneficial while resistant cases may respond to short courses of oral itraconazole or terbinafine.

Scalp seborrheic dermatitis can be helped with topical ketoconazole, zinc pyrithione, selenium sulfide, corticosteroids and tar shampoos, or a propylene glycol preparation formulated for scalp use. Severe cases with marked hyperkeratosis (pityriasis amiantacea) may require topical keratolytics such as salicylic acid ointment or coconut compound ointment.

Specific investigations

In neonates and children consider acrodermatitis enteropathica or transient neonatal zinc deficiency as they may mimic recalcitrant seborrheic dermatitis. A similar eruption in parenterally fed adults can occur due to zinc deficiency.

Non-scalp disease

First-line therapies

image Topical ketoconazole A
image Mild/moderate topical corticosteroids A
image Emollients and soap substitutes D

Second-line therapies

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