144 SEBORRHEIC DERMATITIS SECTION 8 PAPULOSQUAMOUS ...

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MHBD125-144[615-619].qxd 8/18/08 5:48 PM Page 616 PART 13 616 CHAPTER 144 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.)
MHBD125-144[615-619].qxd 8/18/08 5:49 PM Page 617 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.) 617
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144 SEBORRHEIC DERMATITIS SECTION 8 PAPULOSQUAMOUS ...

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