144 SEBORRHEIC DERMATITIS SECTION 8 PAPULOSQUAMOUS ...

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144 SEBORRHEIC
DERMATITIS
Richard P. Usatine, MD
PATIENT STORY
SEBORRHEIC DERMATITIS
A 59-year-old man presents with a 3-month history of an itchy rash
on his face (Figures 144-1 and 144-2). He states that he has had this
rash on and off for many years but this is his worst case. He denies any
major risk factors for HIV and does not have Parkinson’s disease. He
has been under more stress lately and has noticed that this rash has
fla ed up in the past when under increased stress. Note the scale visible
on the forehead and under the eyebrows and beard.There is also
some mild erythema on the cheeks and around the nasolabial folds.
The diagnosis of seborrheic dermatitis is made and treatment is begun
with appropriate topical agents to treat the inflamm tion and the
malassezia. On the following visit the patient has complete clearance
of his seborrheic dermatitis.
EPIDEMIOLOGY
• Seborrhea is most commonly seen in patients aged 20 to 50 years,
and mostly in males.The prevalence of seborrhea is approximately
3% to 5% in young adults who are HIV-negative. 1 The prevalence
of seborrhea is higher in HIV-positive persons, although the vast
majority of persons with seborrhea have a normal immune system.
• Seborrhea is more common in persons with Parkinson’s disease.
• Babies can have seborrhea of the scalp (cradle cap).
ETIOLOGY AND PATHOPHYSIOLOGY
Seborrhea (seborrheic dermatitis) is a superficial inflam tory
dermatitis that is found in regions with a greater number of pilosebaceous
units, which produce sebum. Seborrhea is thought to be caused
by an inflamm tory hypersensitivity to epidermal, bacterial, or yeast
antigens. Persons with seborrhea have a profusion of Pityrosporum
yeast on the skin. Pityrosporum is also called Malassezia (e.g., Malassezia
furfur, Malassezia ovalis).This yeast can be a normal part of skin flora
seborrhea is an inflamm tory reaction to its presence. Seborrhea is
characterized by remissions and exacerbations.The most common
precipitating factors are stress, immunosuppression, and cold
weather.The treatment of seborrhea should be directed at the inflam
mation and the Pityrosporum.
PART 13
DERMATOLOGY
SECTION 8 PAPULOSQUAMOUS CONDITIONS
FIGURE 144-1 Seborrheic dermatitis following the typical distribution
on the face of a 59-year-old man. Note the prominent scale and
erythema on his forehead, glabella, and beard region. (Courtesy of
Richard P. Usatine, MD.)
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DERMATOLOGY
DIAGNOSIS
The diagnosis is made on history and physical examination. Figures
144-1 and 144-2 reveal erythema and scale across the eyebrows,
cheeks, and under beard.
CLINICAL FEATURES
• Seborrhea on the face and scalp can be very pruritic.
• Plaques of greasy scale are visible in the seborrheic distribution.
• In dark-skinned individuals, the involved skin and scale may become
hyperpigmented (Figure 144-3).
• The more severe the seborrhea, the thicker and greasier the scale
(Figure 144-4).
• Infants may develop seborrhea on the scalp, known as cradle cap
(Figure 144-5).They may also have seborrhea on the face around
the eyebrows (Figure 144-6). Some infants have a wider distribution
involving the neck creases, armpits, or groin.
TYPICAL DISTRIBUTION
Scalp (i.e., dandruff), eyebrows (Figures 144-6 and 144-7),
nasolabial creases, forehead, cheeks, around the nose, behind the ears
(Figure 144-8), and under facial hair (Figure 144-9). Seborrhea can
also occur over the sternum and in the axillae, submammary folds,
umbilicus, groin, and gluteal creases.
LABORATORY STUDIES
HIV test if history is suspicious.
DIFFERENTIAL DIAGNOSIS
• SLE with butterf y rash—rash across bridge of nose in patient with
other systemic abnormalities and abnormal blood tests (Chapter
173, Lupus Erythematosus - Systemic and Cutaneous).
• Rosacea—the erythema on the face is often associated with
papules, pustules and possibly chalazia or hordeola (Chapter 107,
Rosacea).
• Psoriasis —the scale of psoriasis tends to be thicker and distributed
over extensor surfaces along with the scalp. Look for signs of nail
involvement that support the diagnosis of psoriasis. (Chapter 145,
Psoriasis).
• Tinea capitis—usually has hair loss with the scale and erythema.
KOH and/or culture can help make the distinction (Chapter 131,
Tinea Capitis).
MANAGEMENT
• Treat the Malassezia with antifungals:
~ Shampoos containing ketoconazole, selenium sulfide or zin
pyrithione (ZPT) are active against the Malassezia and are effective
in the treatment of moderate to severe dandruff. 2,3 SOR
~ Ketoconazole 2% shampoo was found to be superior to zinc
pyrithione 1% shampoo when used twice weekly. Ketoconazole
FIGURE 144-2 Close-up of seborrheic dermatitis showing the flaking
scale and erythema around the beard region. (Courtesy of Richard P.
Usatine, MD.)
FIGURE 144-3 Seborrhea in a black woman with hyperpigmentation
related to the inflammation. Note the prominent involvement in the
nasolabial folds. (Courtesy of Richard P. Usatine, MD.)

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led to a 73% improvement in the total dandruff severity score
compared with 67% for ZPT 1% at 4 weeks. 3 SOR
~ Ciclopirox shampoo 1% is effective and safe in the treatment of
seborrheic dermatitis of the scalp. 4,5 SOR It is by prescription
only and is very expensive.
~ 2% ketoconazole cream, gel, or emulsion is safe and effective for
facial seborrheic dermatitis. 6–8 SOR
~ 1% ciclopirox cream is also safe and effective for facial seborrheic
dermatitis and is equivalent to 2% ketoconazole cream. 6,9
SOR
~ Oral terbinafine 250 mg dai y for 4 weeks is effective for moderate
to severe seborrhea. 10,11 SOR
• Treat the inflamm tion using topical steroids
~ Lotion or solution is preferable on hair-covered area for patient
comfort and usability.
~ 1% Hydrocortisone cream or lotion can be used bid to face,
scalp, or other affected areas. 8,12 SOR
~ Desonide 0.05% lotion is safe and effective for short-term treatment
of seborrheic dermatitis of the face. 13 SOR It is a nonflu
orinated low to mid-potency steroid that is higher in potency
than 1% hydrocortisone.
~ For moderate to severe seborrhea on the scalp.
■ 0.05% Fluocinonide solution once daily is affordable and beneficial
SOR
■ 0.05% Clobetasol shampoo, solution, spray, or foam work well
but are more costly. SOR
OTHER TREATMENTS
• Pimecrolimus cream 1% is an effective and well-tolerated
treatment for facial seborrheic dermatitis. 12,14,15 SOR In one
study, there was more burning noted with the pimecrolimus than
the betamethasone 17-valerate 0.1% cream. 14
• Metronidazole Gel—two small studies have found different results
in the treatment of seborrheic dermatitis on the face. One suggests
it works better than the vehicle alone and the other found no statistically
significant diffe ence from the placebo. 16,17 SOR
• Tea tree oil 5% shampoo showed a 41% improvement in the quadrant-area-severity
score compared with 11% in the placebo. Statistically
significant imp ovements were also observed in the total area
of involvement score, the total severity score, and the itchiness and
greasiness components of the patients’ self-assessments. 18 SOR
• One small RCT (with high drop-out rate) using homeopathic medication
consisting of potassium bromide, sodium bromide, nickel
sulfate, and sodium chloride for 10 weeks showed significan
improvement over placebo. 19 SOR
PATIENT EDUCATION
SEBORRHEIC DERMATITIS
For improved treatment results, encourage patients to wash the hair
and scalp daily with an antifungal shampoo. Some patients fear that
washing their hair too often will cause a “dry” scalp and need to
understand that the scaling and flaking will imp ove rather than
worsen with more frequent hair washing.
PART 13
DERMATOLOGY
FIGURE 144-4 Severe seborrheic dermatitis on the face of a hospitalized
man. The stress of his illness has worsened his otherwise mild seborrhea.
(Courtesy of Richard P. Usatine, MD.)
FIGURE 144-5 Cradle cap in an infant that also has atopic dermatitis.
(Courtesy of Richard P. Usatine, MD.)
FIGURE 144-6 Mild seborrheic dermatitis with subtle flaking around
the eyebrows of a 2-month-old girl who also has cradle cap. (Courtesy
of Richard P. Usatine, MD.)
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FOLLOW-UP
Patients with long-standing and severe seborrhea will appreciate a
follow-up visit in most cases. Milder cases can be followed as needed.
PATIENT RESOURCES
VisualDxHealth - good information and photographs:
http://www.visualdxhealth.com/adult/
seborrheicDermatitis.htm.
http://www.visualdxhealth.com/adult/dandruff.htm.
PROVIDER RESOURCES
eMedicine
http://www.emedicine.com/derm/topic396.htm.
DermNet NZ
http://dermnetnz.org/dermatitis/seborrhoeicdermatitis.htm.
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FIGURE 144-7 Seborrheic dermatitis with erythema and scale under
the eyebrows and in the glabella region on a young man. (Courtesy of
Richard P. Usatine, MD.)
FIGURE 144-8 Seborrheic dermatitis behind the ear in a young
woman. This is a good place to look for evidence of seborrhea. (Courtesy
of Richard P. Usatine, MD.)
FIGURE 144-9 Seborrhea of the beard and mustache distribution with
prominent erythema. (Courtesy of Richard P. Usatine, MD.)

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