Seborrhoeic dermatitis

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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195 Seborrhoeic dermatitis

Instruction

Comment on this patient’s skin.

Salient features

History

• History of itching

• History of Parkinson’s disease, strokes and HIV.

Examination

• Greasy scales overlying erythematous plaques or patches affecting the face (eyebrows, eyelids, glabella, nasolabial folds or ears; Fig. 195.1), submammary folds, gluteal clefts. Occasionally it is generalized.

• Severe dandruff on the scalp.

image

Fig. 195.1 Seborrhoeic dermatitis.

Proceed as follows:

• Tell the examiner that you would like to look for the underlying disorder (Parkinson’s disease, HIV and strokes).

Remember:

• The name is misleading and the condition is unrelated to seborrhoea (excess sebum production).

• Distinguishing severe seborrheic dermatitis from early facial psoriasis can be particularly difficult.

Diagnosis

This patient has seborrhoeic dermatitis (lesion) with Parkinson’s disease, and finds the lesion cosmetically unacceptable (functional status).

Advanced-level questions

What is the aetiology of this disorder?

It is based on a genetic predisposition mediated by several factors including nutritional status, infection and hormones. Its response to antifungal agents has suggested that it represents an inflammatory reaction to Pityrosporum ovale yeasts present in the scalp of humans.

Mention some clinical variants?

• Adult variants:

• Pityriasis capitis (dandruff)
• Blepharitis
• Pityriasiform seborrheic dermatitis: rare form involving the trunk and limbs
• Flexural seborrheic dermatitis: involves any body folds, especially the retroauricular areas, the inner thighs, the genitalia and the breast folds, with intertriginous, sometimes oozing, lesions
• Pitirosporum (malassezia) folliculitis: itchy, erythematous follicular papules, sometimes pustules, typically in sites rich in sebaceous glands; often occurs in immunocompromised hosts
• Erythroderma (exfoliative dermatitis): generalized redness and scaling of the skin with systemic manifestations.

• Infantile variants:

• Scalp seborrheic dermatitis (cradle cap): red-yellow plaques covered by scales on the scalp of infants; develops after a few weeks of age
• Leiner’s disease: poorly defined entity that includes a primary immunodeficiency syndrome not related to seborrheic dermatitis
• Pityriasis amiantacea: thick, asbestos-like scales adhering to tufts of scalp hairs; may be associated with psoriasis, atopic dermatitis, or tinea capitis.

• HIV-related seborrheic dermatitis:

• Occurs particularly in those with CD4 cell counts <400 × 106 cells/l
• Is usually more severe, diffuse and inflammatory than in otherwise healthy persons.

• Drug-related seborrheic-like dermatitis:

• Common in patients treated with erlotinib or sorafenib
• Also reported in patients treated with recombinant interleukin-2, psoralen plus ultraviolet (PUVA).

How would you treat these skin lesions?

• Topical antifungals are the mainstain in treatment, including ketoconazole, bifonazole and ciclopirox olamine (ciclopiroxolamine), which are available in different formulations such as creams, gels, foams and shampoos

• Topical glucocorticoids (avoid fluorinated preparations on the face)

• Shampoos containing coal tar and salicylic acid

• Selenium sulfide shampoos for the scalp

• Eyelid margins respond to gentle cleaning of lid margins with undiluted Johnson and Johnson baby shampoo using a cotton swab

• Oral ketoconazole is invaluable in the persistent seborrhoeic dermatitis of AIDS but should rarely be used otherwise

• Topical lithium succinate and lithium gluconate are effective alternatives for the treatment of seborrheic dermatitis in areas other than the scalp

• Topical 1% pimecrolimus.

What is the prognosis of this condition?

There is a tendency to lifelong recurrences.

Further reading

Naldi L, Rebora A. Seborrheic dermatitis. N Engl J Med. 2009;360:387-396.

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