Seborrheic dermatitis in adolescents and adults

Seborrheic dermatitis - Facial redness and scale involving the nasolabial folds and central face
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SUMMARY AND RECOMMENDATIONS

● Seborrheic dermatitis is a chronic, relapsing, and usually mild form of dermatitis of unknown origin occurring in areas rich in sebaceous glands (scalp, face, upper trunk, intertriginous areas); indirect evidence supports a pathogenetic role for the Malassezia yeast.

● The mildest and most common form of scalp seborrheic dermatitis is dandruff, a fine, white, diffuse scaliness of the scalp without underlying erythema. Manifestations of severe seborrheic dermatitis of the scalp or other body sites include inflamed, erythematous plaques covered with yellowish, greasy scales (picture 1C, 1E).

● The diagnosis of seborrheic dermatitis is usually made clinically based on the appearance and location of the lesions. The differential diagnosis of seborrheic dermatitis includes psoriasis (picture 4), rosacea (picture 7A-E), tinea versicolor (picture 8), pityriasis rosea (picture 9A-B), tinea corporis (picture 10), secondary syphilis, lupus erythematosus (picture 11A-B), and pemphigus foliaceous (picture 12A-B). These conditions can be differentiated clinically and/or through laboratory tests and histology.

● Several randomized trials indicate that topical corticosteroids and topical antifungal agents are effective for treating seborrheic dermatitis and that intermittent topical antifungals may prevent relapse. However, the high response in the placebo groups suggests that frequent shampooing or regular use of emollients may also be beneficial.

● For patients with seborrheic dermatitis of the scalp we suggest treatment with antifungal shampoos (selenium sulfide 2.5%, ketoconazole 2%, or ciclopirox 1%) rather than frequent shampooing with nonmedicated shampoo (Grade 2B). Alternative medicated shampoos include coal tar, salicylic acid, and sulfur, alone or in combination, available over the counter as shampoos or lotions. The medicated shampoo should be used daily or two or three times per week for several weeks, until remission is achieved.

In addition, for patients with itching and/or visible inflammation (patchy, orange to salmon-colored plaques covered with scale), we suggest treatment with a high potency (group three to one) corticosteroid shampoo, lotion, or foam (table 1) (Grade 2B). The topical corticosteroid should be applied once daily for two to four weeks.

For long-term control of seborrheic dermatitis of the scalp, we suggest ketoconazole 2% shampoo or ciclopirox 1% shampoo once per week (Grade 2B).

● For initial treatment of patients with seborrheic dermatitis of the face, we suggest treatment with low-potency (groups 6 or 7) topical corticosteroid cream (table 1), or topical antifungal agent (ketoconazole 2% cream, other azole creams, or ciclopirox 1% cream), or a combination of the two (Grade 2C). The topical therapy is applied to the affected areas once or twice daily only until symptoms subside.

For men with seborrheic dermatitis of the face who have mustaches and beards, we suggest ketoconazole 2% shampooing of the facial hair (Grade 2C). The shampoo is used daily until remission and then once per week. A low-potency corticosteroid (group 7 (table 1)) can be added to the initial treatment to control inflammation and itching.

For long-term control of facial seborrheic dermatitis, we suggest ketoconazole 2% cream or shampoo, other azole cream, or ciclopirox 1% cream once per week (Grade 2C).

● For patients with seborrheic dermatitis of the trunk and intertriginous areas, we suggest treatment with mid-potency (groups 5 or 4) topical corticosteroid cream (table 1) or topical antifungal agents, or a combination of the two (Grade 2C). The topical therapy is applied to the affected areas once or twice daily only until symptoms subside.

For long-term control of seborrheic dermatitis of the trunk and intertriginous areas, we suggest ketoconazole 2% cream or shampoo, other azole cream, or ciclopirox 1% cream once per week (Grade 2C).

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