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Seborrheic eczema
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 relapsing dermatitis affecting between 3% and 10% of adults, becoming more prevalent with age. It accounts for up to 3.5% of dermatology specialist outpatient consultations. It is more common in patients with Parkinson disease, HIV, AIDS, and alcohol dependency.
The signs and symptoms comprise erythema, greasy scaling, pruritus, burning, and dryness in a typical distribution pattern affecting the scalp and the face (particularly the nasolabial folds, eyebrows, and ears). 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.
Management Strategy
Seborrheic eczema 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, whereas 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, corticosteroid and tar shampoos, or a propylene glycol preparation formulated for scalp use. Severe cases with marked hyperkeratosis or pityriasis amiantacea may require topical keratolytics such as salicylic acid ointment or coconut compound ointment.
In neonates and children, consider acrodermatitis enteropathica or transient neonatal zinc deficiency, which can mimic recalcitrant seborrheic dermatitis. A similar eruption in parenterally fed adults also can occur due to zinc deficiency.
Dermoscopy can be useful in differentiating scalp psoriasis from seborrhoeic dermatitis
Kim GW, Jung HJ, Ko HC, et al. Br J Dermatol 2011; 164: 652–6.
Dermoscopy features on the scalp include arborizing vessels and comma vessels.
This may be of value as a means of differentiating from scalp psoriasis. These findings appear to have been replicated in several later studies.
New insights into HIV-1-primary skin disorders
Cedeno-Laurent F, Gömez-Flores M, Mendez N, et al. Int AIDS Soc 2011; 24: 14–5.
This article reports seborrheic dermatitis in up to 40% of patients with HIV with worsening severity as lymphocyte counts decline. Incidence in AIDS patients is up to 80%.
Seborrheic dermatitis and risk of future Parkinson’s disease (PD)
Tanner C, Albers K, Goldman S, et al. Neurology 2012; 78 (Meeting Abstracts 1): S42.001.
This nested case-control study included 2651 PD cases and 13,255 controls. Seborrheic eczema was associated with increased risk of PD (OR = 1.69, 95% CI 1.36, 2.1; p < 0.001). PD risk was also increased when seborrheic dermatitis was diagnosed 5 or more years before (2.1% cases, 1.4% controls, OR = 1.42, 95% CI 1.05, 1.93; p = 0.024).
Cutaneous changes in chronic alcoholics
Rao GS. Indian J Dermatol Venereol Leprol 2004; 70: 79–81.
In this study of 200 alcoholic patients attending for alcohol detoxification, seborrheic dermatitis was the second most common skin disorder (11.5% of cases).
Non-Scalp Disease
First-Line Therapies
Ketoconazole 2% cream versus hydrocortisone 1% cream in the treatment of seborrhoeic dermatitis. A double-blind comparative study
Stratigos JD, Antoniou C, Katsambas 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 compared with 94.4% of the hydrocortisone group. There was no significant difference in relapse rates.
Topical antifungals for seborrhoeic dermatitis
Okokon EO, Verbeek JH, Ruotsalainen JH, et al. Cochrane Database Syst Rev 2015; 5: CD008138.
This review included 51 studies with a total of 9052 participants. Eight trials compared use of topical 2% ketoconazole with placebo or vehicle. Active treatment was associated with a 31% lower risk of failure of clearance. Six trials compared topical ketoconazole with topical steroids. Remission rates were similar (RR 1.17, 95% CI 0.58–1.64), but occurrence of side effects was 44% lower in the ketoconazole group. Quality of data was limited by study duration and heterogeneity between studies.
Lithium gluconate 8% vs. ketoconazole 2% in the treatment of seborrhoeic dermatitis: a multicenter, randomized study
Dreno B, Chosidow O, Revuz J, et al. Br J Dermatol 2003; 148: 1230–6.
This randomized, noninferiority 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, in moderate-to-severe seborrheic dermatitis. Two hundred and sixty-nine patients were treated, and complete response was achieved in 52.0% and 30.1%, respectively.
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