Seborrheic Dermatitis Management

Antibiotics¹

Antistaphylococcal penicillins (oral) should be used in cases of secondary bacterial infection. Infection should be controlled before applying topical corticosteroids.

Metronidazole

A topical form of Metronidazole may be used for the treatment of facial seborrheic dermatitis with coexisting rosacea. Metronidazole has comparable therapeutic effects on topical Ketoconazole.

Antifungals (Oral)¹ 

Example drugs: Fluconazole, Itraconazole, Ketoconazole, Terbinafine

Oral antifungals are indicated for non-scalp and widespread or refractory seborrheic dermatitis.

Itraconazole

Itraconazole may be used for patients with persistent seborrheic dermatitis resistant to topical therapies. A 7-day treatment course of Itraconazole resulted in substantial improvement in approximately 75% of patients. The drug also has anti-inflammatory properties.

Terbinafine 







A 4-week treatment regimen of Terbinafine led to improvements in erythema, scaling, and pruritus. This drug is significantly more effective than placebo in reducing dermatitis severity in non-exposed skin areas.

Antifungals (Topical)

Topical antifungals reduce Malassezia population. These are used for scalp, non-scalp, and refractory seborrheic dermatitis.

Allylamines

Example drugs: Naftifine, Terbinafine

Allylamines inhibit the fungal enzyme squalene epoxidase, thereby interfering with ergosterol biosynthesis. These are effective in reducing scalp, face, and body seborrhea.

Azole Derivatives

Example drugs: Ketoconazole, Miconazole, Sertaconazole

Azole derivatives act by reducing fungal ergosterol synthesis by inhibiting the fungal cytochrome P450 enzymes. There is decreased colonization by lipophilic yeast. Ketoconazole is as effective as a corticosteroid and is a good treatment alternative in infants. These effectively reduce erythema, pruritus, and scaling in mild to severe seborrheic dermatitis of the scalp and body. Prolonged use is associated with adverse effects (eg decreased biosynthesis of adrenal and gonadal steroid hormones). These may also be considered an alternative to keratolytics when applied to affected areas for 5-10 minutes before rinsing.

Ciclopirox (Ciclopiroxolamine, Ciclopirox olamine)

Ciclopirox has a wide spectrum of antifungal activity as well as some anti-inflammatory and antibacterial activity. This is used for scalp and non-scalp seborrheic dermatitis and effective against even the most difficult and diffuse cases.

Calcineurin Inhibitors (Topical)

Example drugs: Pimecrolimus, Tacrolimus

Calcineurin inhibitors inhibit inflammatory cytokine transcription in activated T cells and other inflammatory cells through inhibition of calcineurin. These have fungicidal and anti-inflammatory properties without causing cutaneous atrophy. These are good therapeutic options when the face and other parts of the body other than the scalp are affected. Calcineurin inhibitors are an alternative treatment for mild to severe refractory seborrheic dermatitis. At least 1 week of daily use is necessary before benefits become apparent. These are not recommended in patients <2 years of age. Long-term use should be avoided and should be limited to involved areas only.

Corticosteroids 







Oral Corticosteroids

Example drugs: Methylprednisolone, Prednisone

Oral corticosteroids may be considered as a systemic treatment option for recalcitrant moderate-to-severe seborrheic dermatitis patients unresponsive to or with contraindications to oral antifungals. Prolonged or frequent use should be avoided and gradual tapering is recommended.

Topical Corticosteroids

Example drugs: Alclometasone, Betamethasone valerate, Clobetasol propionate, Desonide, Fluocinolone, Hydrocortisone

Topical corticosteroids act by reducing the concentration of peripheral leukocytes in the inflammatory site and redistributing them to lymphoid tissue. These suppress the effects of inflammatory cytokines, chemokines, and other lipid and glycolipid mediators of inflammation. Topical corticosteroids are used primarily for the anti-inflammatory activity in moderate to severe seborrheic dermatitis but also have antimitotic effects on the epidermis. Solution and ointment are useful for scalp lesions, while lotions and creams are appropriate for the face and other parts of the body. Mildly potent corticosteroids are preferred to minimize the risk of toxicity (eg skin atrophy, telangiectasia). Very potent corticosteroids are not recommended for >2 weeks and must be discontinued as soon as treatment response is noted.

Emollients

Example drugs: Bisabolol, Glycyrrhetic acid, Piroctone olamine, Shea butter (Butyrospermum parkii), Tea tree oil (Melaleuca alternifolia), Vitis vinifera

Emollients may be used for the relief of symptoms, especially in patients with mild scalp and non-scalp seborrheic dermatitis. These reduce scaling in infants with a cradle cap.

Keratolytic Agents

Keratolytic agents are used to prevent scaling or crust formation and help improve the penetration of other topical treatment agents. Anti-dandruff shampoo containing a keratolytic agent should be used at least every other day.

Coal Tar

Coal tar is useful in treating dense seborrhea of the scalp, face, and body. The phenolic constituents of coal tar account for its antipruritic effect.

Lipohydroxy Acid

Lipohydroxy acid may be used for the treatment of seborrheic dermatitis of the scalp. This has both antifungal and exfoliating properties. Studies have shown that Lipohydroxy acid is comparable to the effect of Ciclopiroxolamine on seborrheic dermatitis patients.

Propylene Glycol

Propylene glycol may be used for mild to severe seborrheic dermatitis of the scalp. Studies showed improvement of erythema and desquamation with daily application after 4 weeks. This possesses humectant properties and moisturizes and protects the skin.

Salicylic Acid

Salicylic acid is effective in removing dense scales. The exact mechanism is unknown, although Salicylic acid may solubilize cell surface proteins that keep the stratum corneum intact, resulting in desquamation of keratotic debris.

Selenium Sulfide

Selenium sulfide may be used in treating seborrhea of the scalp, face, and body. This has both keratolytic and antifungal activity.

Sulfur

Sulfur exerts keratolytic action through its ability to form hydrogen sulfide on contact with keratinocytes.

Zinc Pyrithione 







Zinc pyrithione exerts non-specific keratolytic activity and decreases colonization by lipophilic yeast. This possesses antibacterial and antifungal activity. This may be used for the treatment of mild seborrheic dermatitis of the scalp.

Nonsteroidal Anti-inflammatory with Antifungal Properties (AIAFp)¹

Alglycera, Bisabolol, Glycyrrhetic acid, Piroctone olamine and Telmesteine have both anti-inflammatory and antifungal properties. Piroctone olamine/Bisabolol/Glycyrrhetic acid/Lactoferrin shampoo is an example of AIAFp used in scalp seborrheic dermatitis. AIAFp is used for non-scalp SD, including Piroctone olamine/Alglycera/Bisabolol cream and Piroctone olamine/Bisabolol/Alglycera/Telmesteine cream.

Phosphodiesterase Type-4 (PDE-4) Inhibitor

Roflumilast

Roflumilast is a highly potent PDE-4 inhibitor with anti-inflammatory properties. Topical Roflumilast 0.3% foam was approved in 2024 by the United States Food and Drug Administration for the treatment of seborrheic dermatitis in adults and children ≥9 years of age. A once-daily use of Roflumilast 0.3% foam showed favorable efficacy, safety, and tolerability in the treatment of seborrheic dermatitis in both scalp and body in phase 2a and 3 clinical trials.

Retinoids¹

Retinoids may be used as an alternative therapy in refractory disease. The lowest dose of retinoids is recommended. These reduce sebaceous gland activity.

Other Therapies

Other nonsteroidal combination therapies¹ containing antioxidants (ie Tocopheryl acetate, Telmesteine) may help relieve symptoms. The use of Crisaborole may be considered in patients requiring frequent use of topical corticosteroids.

¹Various products are available. Please see the latest MIMS for specific formulations and prescribing information. 

Patient or Caregiver Education

Advise the caregiver that cradle cap is a benign self-limiting condition that generally resolves within the first year of life without therapy. Reassure the patient or caregiver that seborrheic dermatitis does not cause permanent hair loss. Emphasize that treatment does not cure the disease permanently and must be repeated when symptoms recur. Instruct the caregiver on how to apply topical treatments effectively.

Scalp and Skin Care¹

Frequent cleansing of the affected areas with soap removes oils and improves seborrhea. Moisturizing emollients should be used after washing the skin. To remove dense scales on the scalp, apply warm mineral oil or olive oil to the scalp and rinse several hours later with a detergent (eg dishwashing liquid) or a tar shampoo. Leave a coal tar-keratolytic combination or phenol-saline solution overnight and shampoo it off in the morning. Seborrheic blepharitis may respond to gentle cleaning of eyelashes with baby shampoo and cotton applicators. Minimize hairspray, gel, and sunlight exposure.

Wet Compress

A wet compress should be applied to moist or fissured lesions before applying topical corticosteroids.

¹Various products are available. Please see the latest MIMS for specific formulations and prescribing information.

Phototherapy

Phototherapy may be used as an alternative treatment in patients with widespread or refractory seborrheic dermatitis. UVA and UVB inhibit the growth of Malassezia. Many patients experience improvements in seborrhea during the summer months, possibly due to sun exposure. In cases of combination treatment failure in patients with refractory or widespread seborrheic dermatitis, short-term use of a more potent corticosteroid in a pulse fashion may be effective.