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Seborrhoeic dermatitis - Management
How should I treat?

  • Consider ketoconazole 2% cream (or other topical imidazole) in all people with seborrhoeic dermatitis of the face and body. Continue treatment until the skin has improved to a level that is acceptable to the person.
  • Consider the addition of a mild topical corticosteroid cream, such as hydrocortisone 1% (or use of a combined imidazole and hydrocortisone preparation) to settle inflammation more quickly. Hydrocortisone 1% is well tolerated in long-term use (up to 6 months), but specialist advice should be sought if symptoms have not resolved at 6 months, or sooner if response to treatment is poor:
    • The use of topical corticosteroids needs to be balanced against their potential for adverse effects, particularly in people requiring treatment for frequent relapses.
  • If the eyelids are involved, consider daily hygiene measures using cotton buds moistened with baby shampoo. If this is not effective, seek specialist advice regarding further treatment.
Clarification / Additional information
Basis for recommendation
  • Ketoconazole cream:
    • Evidence from two small RCTs discussed in a systematic review [Manriquez and Uribe, 2007], suggests benefits from ketoconazole cream in the treatment of seborrhoeic dermatitis of the body and face, compared with placebo.
    • CKS has extrapolated evidence from ketoconazole to other imidazole creams on the basis of feedback from expert reviewers and their similar safety profiles in terms of absorption.
  • Topical corticosteroid:
    • CKS found no evidence comparing a topical corticosteroid with placebo for treating seborrhoeic dermatitis of the face or body. However, a systematic review [Manriquez and Uribe, 2007], concluded that although evidence is lacking, consensus regards the use of topical corticosteroids as effective for this purpose.
    • CKS has extrapolated evidence on the effective use of corticosteroids for scalp seborrhoeic dermatitis (see Seborrhoeic dermatitis of the scalp and beard) in the absence of evidence specific to the face and body.
    • In general, the use of a topical corticosteroid alone is not recommended.
    • CKS could find no evidence for the duration of treatment with hydrocortisone, but have based the recommendation on feedback from expert reviewers.
  • Combination products:
    • Feedback from expert reviewers suggests that combination imidazole and hydrocortisone products may be useful if both components are required:
      • The British National Formulary [BNF 55, 2008], advises against the use of topical ketoconazole within 2 weeks of a topical corticosteroid for seborrhoeic dermatitis, as there is a risk of skin sensitization. However, feedback from expert reviewers does not support this.
  • Treatment of seborrhoeic dermatitis of the eyelid (seborrhoeic blepharitis):
    • The authors of a dermatology textbook [Plewig and Jansen, 2008], suggest eyelid hygiene using hot compresses along with cotton buds and baby shampoo for seborrhoeic blepharitis.
    • A small trial comparing eyelid hygiene with topical 2% ketoconazole cream found a similar reduction in symptoms and signs of inflammation in both groups [Nelson et al, 1990]. In view of the comparative effectiveness and the fact that manufacturers advise avoiding use of ketoconazole cream in the ophthalmic area [ABPI Medicines Compendium, 2008c], CKS recommends eyelid hygiene first-line and seeking specialist advice regarding further treatment if this is not effective.
    • CKS does not recommended the use of topical corticosteroids on the eyelid, as adverse effects, including increased intraocular pressure or cataracts, may result [BNF 55, 2008].

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