Published on 16/03/2015 by admin
Filed under Dermatology
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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.
A double-blind, placebo-controlled, multicenter trial of lithium succinate ointment in the treatment of seborrhoeic dermatitis.
The Efalith Multicenter Trial Group. J Am Acad Dermatol 1992; 26: 452–7.
This placebo-controlled, double-blind study in 227 patients showed that lithium succinate ointment was significantly more effective than placebo in treating all symptoms of non-scalp seborrheic dermatitis.
Lithium gluconate 8% vs ketoconazole 2% in the treatment of seborrhoeic dermatitis: a multicentre, randomized study.
Dreno B, Chosidow O, Revuz J, Moyse D. Br J Dermatol 2003; 148: 1230–6.
This randomized, non-inferiority study compared 8% lithium gluconate twice daily for 8 weeks with ketoconazole 2% twice weekly for 4 weeks then once weekly for a further 4 weeks. A total of 269 patients were treated and complete response was achieved in 52.0% and 30.1% respectively.
Randomized, placebo-controlled, double-blind study on clinical efficacy of ciclopiroxolamine 1% cream in facial seborrhoeic dermatitis.
Dupuy P, Maurette C, Amoric JC, Chosidow O. Br J Dermatol 2001; 144: 1033–7.
One hundred and twenty-nine patients were randomized to receive either ciclopiroxolamine 1% cream twice daily for 28 days, followed by once-daily application for a further 28 days, or placebo. At 8 weeks 63% of patients in the ciclopiroxolamine group achieved clearance of their test lesions versus 34% of placebo patients (p<0.007).
Pimecrolimus 1% cream, methylprednisolone aceponate 0.1% cream and metronidazole 0.75% gel in the treatment of seborrhoea dermatitis: a randomized clinical study.
Cicek D, Kandi B, Bakar S, Turgut D. J Dermatol Treat 2009; 20: 344–9.
In this prospective, randomized control trial, 64 patients received either pimecrolimus 1% cream, methylprednisolone aceponate 0.1% cream or metronidazole 0.75% gel to apply twice daily for 8 weeks. All groups showed improvement in redness, scaling, and itch. Pimecrolimus was significantly more effective than the other treatments (p<0.05).
Single-blind, randomized controlled trial evaluating the treatment of facial seborrheic dermatitis with hydrocortisone 1% ointment compared with tacrolimus 0.1% ointment in adults.
Papp KA, Papp A, Dahmer B, Clark CS. J Am Acad Dermatol 2012; 67: e11–15.
Thirty patients received either hydrocortisone 1% cream or tacrolimus 0.1% ointment twice daily to symptomatic areas for 12 weeks. Both groups showed improvement in clinical severity with patients using tacrolimus needing fewer applications of treatment.
Oral terbinafine in the treatment of multi-site seborrheic dermatitis: a multicentre, double-blind placebo-controlled study.
Vena GA, Micala G, Santoianni P, Cassano N, Peruzzi E. Int J Immunopathol Pharmacol 2005; 18: 745–53.
One hundred and seventy-four patients with seborrheic dermatitis were randomized to receive either terbinafine 250 mg once daily or placebo for 6 weeks. Terbinafine was statistically more effective at achieving 50% improvement than placebo in non-exposed sites (70% vs 45%) and in achieving patient satisfaction (66% vs 40%). There was no statistical difference in patients with lesions on exposed sites.
Oral itraconazole for the treatment of seborrhoeic dermatitis: an open, non-comparative trial.
Kose O, Erbil H, Gur AR. J Eur Acad Dermatol Venereol 2005; 19: 172–5.
Twenty-nine patients with seborrheic dermatitis not responsive to conventional therapy received either 200 mg of itraconazole daily for 7 days every fourth week or 200 mg of itraconazole for 2 days of each week. Regimens were not compared, but treatment was effective in 61%.
Metronidazole 0.75% gel vs. ketoconazole 2% cream in the treatment of facial seborrheic dermatitis: a randomized, double blind study.
Seckin D, Gurbuz O, Akin O. J Eur Acad Dermatol Venereol 2007; 21: 345–50.
Sixty patients with facial seborrheic dermatitis used either 0.75% metronidazole gel (with ketoconazole cream as vehicle) or 2% ketoconazole cream (with metronidazole gel as vehicle) for 4 weeks. Around 80% improvement was noted in both groups, with no statistical difference.
An investigator-blind, randomized, 4-week, parallel-group, multicenter pilot study to compare the safety and efficacy of a nonsteroidal cream (Promiseb Topical Cream) and desonide cream 0.05% in the twice-daily treatment of mild to moderate seborrheic dermatitis of the face.
Elewski B. Clin Dermatol 2009; 27(6 Suppl): S48–53.
This investigator-blind study randomized 77 volunteers to twice daily application of non-steroidal cream or desonide 0.05% cream for up to 28 days. Both treatments were similarly effective achieving ‘clear’ or ‘almost clear’ in approximately 90% of participants with significant improvements in clinical signs.
Narrow-band ultraviolet B (TL-01) phototherapy is an effective and safe treatment option for patients with severe seborrhoeic dermatitis.
Pirkhammer D, Seeber A, Honigsmann H, Tanew A. Br J Dermatol 2000; 143: 964–8.
Eighteen patients were treated three times weekly until complete clearing or to a maximum of 8 weeks. Six showed complete clearance and 12 demonstrated marked improvement.
Benzoyl peroxide in seborrheic dermatitis.
Bonnetblanc JM, Bernard P. Arch Dermatol 1986; 122: 752.
Twenty-eight of 30 patients showed improvement with 1 week’s use of 2.5% benzoyl peroxide preparation. All relapsed within 2 to 12 weeks of stopping treatment.
Efficacy of terbinafine 1% cream on seborrheic dermatitis.
Gündüz K, Inanir I, Sacar H. J Dermatol 2005; 32: 22–5.
Thirty-five patients were treated with terbinafine 1% cream twice daily for 4 weeks. Complete remission was seen in 32% of cases.
Successful treatment and prophylaxis of scalp seborrhoeic dermatitis and dandruff with 2% ketoconazole shampoo: results of a multicentre, double-blind, placebo-controlled trial.
Peter RU, Richarz-Barthauer U. Br J Dermatol 1995; 132: 441–5.
Five hundred and seventy-five patients with moderate to severe scalp seborrheic dermatitis and dandruff were treated with ketoconazole 2% shampoo twice weekly for 2 months, producing clearance in 88%. Three-hundred and twelve responders were then randomized to active treatment or placebo once weekly. There were fewer relapses in the ketoconazole prophylactic treatment group after 6 months (47% vs 19%).
Treatment and prophylaxis of seborrheic dermatitis of the scalp with antipityrosporal 1% ciclopirox shampoo.
Shuster S, Meynadier J, Kerl H, Nolting S. Arch Dermatol 2005; 141: 47–52.
In this double-blind vehicle control trial, 949 patients received ciclopirox 1% shampoo twice or once weekly, or vehicle. After 4 weeks responders were randomized for maintenance therapy with one of the three regimens for a further 12 weeks. At 4 weeks both ciclopirox regimens were statistically more effective than placebo (response rates 57.9 vs 45.4 vs 31.6). During the maintenance phase relapse rates were significantly lower for both active regimens compared to placebo (14.9% vs 22.1% vs 35.5%).
Clinical efficacies of shampoos containing ciclopirox olamine (1.5%) and ketoconazole (2%) in the treatment of seborrheic dermatitis.
Ratnavel RC, Squire RA, Boorman GC. J Dermatol Treat 2007; 18: 88–96.
This randomized, double-blind study enrolled 350 patients to compare ciclopirox 1.5% shampoo with ketoconazole 2% shampoo and placebo over a period of 4 weeks. Ciclopirox shampoo and ketoconazole shampoo were both significantly more effective than placebo.
A multicenter randomized trial of ketoconazole 2% and zinc pyrithione 1% shampoos in severe dandruff and seborrheic dermatitis.
Piérard-Franchimont C, Goffin V, Decroix J, Piérard GE. Skin Pharmacol Appl Skin Physiol 2002; 15: 434–41.
In this 4-week open-label randomized trial, 331 patients with either seborrheic dermatitis or dandruff were randomized to either twice weekly ketoconazole 2% shampoo or at least twice weekly zinc pyrithione 1% shampoo. Both groups showed clinical benefit with reductions in dandruff severity of 73% and 61%, respectively.
Propylene glycol in the treatment of seborrhoeic dermatitis of the scalp: a double-blind study.
Faergemann J. Cutis 1988; 42: 69–71.
Thirty-nine patients with scalp seborrheic dermatitis were treated in a double-blind controlled study with 15% propylene glycol formulated for scalp use or vehicle alone: 89% in the group treated with propylene glycol showed healing compared to 32% of the control group.
A randomized, double-blind, placebo-controlled trial of ketoconazole 2% shampoo versus selenium sulfide 2.5% shampoo in the treatment of moderate to severe dandruff.
Danby FW, Maddin WS, Margeson LJ, Rosenthal D. J Am Acad Dermatol 1993; 29: 1008–12.
In 236 patients, both medicated shampoos were statistically better than placebo in treating scaling and itching. However, ketoconazole was superior to selenium shampoo, and was also better tolerated.
Seborrhoeic dermatitis and Pityrosporum orbiculare: treatment of seborrhoeic dermatitis of the scalp with miconazole-hydrocortisone (Daktacort), miconazole and hydrocortisone.
Faergemann J. Br J Dermatol 1986; 114: 695–700.
In this double-blind randomized control study, 70 patients received miconazole 2% base and hydrocortisone 1% (Daktacort), miconazole 2% base, or hydrocortisone 1% daily for 3 weeks. The drugs were incorporated into a solution of 60% ethyl alcohol, 10% propylene glycol, and purified water. After 3 weeks, responders moved to maintenance therapy with the same agent for a further 3 weeks. Non-responders continued with daily application. All three groups showed reduced organism culture and clinical improvement with 82.6%, 65.2% and 29.1% deemed clear in each group.
Clinical efficacies of topical agents for the treatment of seborrheic dermatitis of the scalp: a comparative study.
Shin H, Kwon OS, Won CH, Kim BJ, Lee YW, Choe YB, et al. Dermatol 2009; 36: 131–7.
In this randomized open-label study, 83 patients were treated with twice daily betamethasone 17-valerate lotion, tacrolimus 0.1% ointment or three times weekly zinc pyrithione 1% shampoo for 4 weeks. At week 4, 33 patients continued treatment while the others stopped active therapy. At 4 weeks all groups showed clinical improvement with tacrolimus significantly more effective than zinc pyrithione. Prolonging tacrolimus use did not incur any additional therapeutic benefit, but patients in the zinc pyrithione and betamethasone valerate groups continued to improve.
Efficacy of betamethasone valerate 0.1% thermophobic foam in seborrhoeic dermatitis of the scalp: an open-label, multicentre, prospective trial on 180 patients.
Milani M, Antonio Di Molfetta S, Gramazio R, Fiorella C, Frisario C, Fuzio E, et al. Curr Med Res Opin 2003; 19: 342–5.
In this open-label trial, 180 patients were treated with 2 g of betamethasone 17-valerate 0.1% foam daily for 15 days then every other day for 15 days. At 4 weeks there was a statistically significant clinical improvement. Eighty-five percent of patients preferred the betamethasone foam to previous treatments.
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.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Topical ketoconazole
Mild/moderate topical corticosteroids
Emollients and soap substitutes
Lithium succinate/lithium gluconate
Ciclopiroxolamine cream
Topical calcineurin inhibitors
Oral terbinafine
Oral itraconazole
Metronidazole gel
Non-steroidal cream
Phototherapy
Benzoyl peroxide
Topical terbinafine
Ketoconazole shampoo
Ciclopirox shampoo
Zinc pyrithione shampoo
Propylene glycol lotion
Potent/superpotent topical corticosteroids
Tacrolimus ointment
Miconazole
Selenium sulfide shampoo
