Published on 16/03/2015 by admin
Filed under Dermatology
Last modified 16/03/2015
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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
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.
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.
Tests for HIV infection
Zinc levels
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.
New insights into HIV-1-primary skin disorders.
Cedeno-Laurent F, Gómez-Flores M, Mendez N, Ancer-Rodríguez J, Bryant JL, Gaspari AA, et al. Int AIDS Soc 2011; 24: 14–15.
This review article reports seborrheic dermatitis in up to 40% of patients with HIV with worsening severity as lymphocyte counts decline. Incidence in patients with AIDS is up to 80%.
Seborrheic dermatitis in neuroleptic-induced Parkinsonism.
Binder RL, Jonelis FJ. Arch Dermatol 1983; 119: 473–5.
Comparison of 42 hospitalized patients with drug-induced Parkinsonism using psychiatric patients as controls showed an incidence of seborrheic dermatitis of 59.5% in those with Parkinsonism, compared to 15% of controls.
Cutaneous changes in chronic alcoholics.
Rao GS. Indian J Dermatol Venereol Leprol 2004; 70: 79–81.
In this study of 200 alcoholic patients seborrheic dermatitis was the second most common skin disorder (11.5% of cases) after tinea versicolor (14% of cases).
Ketoconazole 2% cream versus hydrocortisone 1% cream in the treatment of seborrhoeic dermatitis. A double-blind comparative study.
Stratigos JD, Antoniou C, Katsambas A, Böhler K, Fritsch P, Schmölz A, et al. J Am Acad Dermatol 1988; 19: 850–3.
In this double-blind study, 72 patients were treated daily for 4 weeks with either ketoconazole 2% cream or hydrocortisone 1% cream; 80.5% of the ketoconazole group showed a significant improvement in all symptoms versus 94.4% of the hydrocortisone group. There was no significant difference in relapse rates between the two groups.
Comparative study of ketoconazole 2% foaming gel and betamethasone dipropionate 0.05% lotion in the treatment of seborrhoeic dermatitis in adults.
Ortonne JP, Lacour JP, Vitetta A, Le Fichoux Y. Dermatology 1992; 184: 275–80.
In this single-blind study, 62 patients received either ketoconazole 2% foaming gel or betamethasone dipropionate 0.05% lotion for 4 months. Global evaluation by participating physicians and patients showed response rates of 89% and 89% for ketoconazole and 62% and 65% for betamethasone. The ketoconazole group also showed a statistically significant reduction in the number of Pityrosporum ovale.
Randomised double blind controlled trial of 2% ketoconazole cream versus 0.05% clobetasol 17-butyrate cream in seborrhoeic dermatitis.
Pari T, Pulimood S, Jacob M, George S, Jeyaseelan L, Thomas K. J Eur Acad Dermatol Venereol 1998; 10: 89–90.
In this randomized control trial, 36 patients were treated with twice daily ketoconazole 2% cream or 0.05% clobetasol 17-butyrate cream. Complete remission rates were 64.4% and 63.2% respectively. At 3 months, recurrence rates were 30% and 50%.
A novel foam formulation of ketoconazole 2% for the treatment of seborrheic dermatitis on multiple body regions.
Elewski BE, Abramovits W, Kempers S, Schlessinger J, Rosen T, Gupta AK, et al. J Drugs Dermatol 2007; 6: 1001–8.
In this randomized control trial, 1162 patients with skin and scalp seborrheic dermatitis received either ketoconazole 2% foam (n=427), vehicle foam (n=420), ketoconazole 2% cream (n=210), or vehicle cream (n=105) twice daily for 4 weeks. Fifty-six percent of patients using ketoconazole foam improved compared with 42% using placebo. Ketoconazole foam was shown to be equivalent to ketoconzole cream.
Other topical azole preparations (bifonazole and sertaconazole creams) have demonstrable efficacy in non-scalp sites.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Topical ketoconazole
Mild/moderate topical corticosteroids
Emollients and soap substitutes
