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Seborrhoeic dermatitis - Management
How should I treat?

  • Remove thick crusts or scales on the scalp before using an antifungal shampoo. Removal of crusts can be achieved by:
    • Applying warm mineral or olive oil to the scalp for several hours, then washing with a detergent or coal tar shampoo, or
    • Application of a keratolytic preparation (e.g. salicylic acid) or coal tar–keratolytic preparation.
  • Prescribe ketoconazole 2% shampoo if it has not been tried already. Selenium sulphide shampoo may be used as an alternative.
  • If ketoconazole or selenium sulphide is not acceptable to the person, treat with anti-dandruff shampoos (e.g. containing coal tar or salicylic acid) which are available over-the-counter, after confirming that they have not been tried already. Shampoo can also be applied to the beard area.
  • For adults with severe itching, add a potent topical corticosteroid scalp application, such as betamethasone valerate 0.1%, hydrocortisone butyrate 0.1%, or mometasone furoate 0.1%. Try 4–6 weeks of treatment (to the scalp, not the beard). If symptoms have not resolved after this time, seek specialist advice, or sooner if response to treatment is poor.
  • Once symptoms are under control, the frequency of shampooing with medicated shampoos may be reduced or stopped.
Basis for recommendation
  • Removal of scale:
    • The recommendation to remove adherent crusts or scales is based on a review of the treatment of seborrhoeic dermatitis [Johnson and Nunley, 2000] and a patient information leaflet from the British Association of Dermatologists [BAD, 2004]:
    • CKS infers that removing scale will improve the effectiveness of the antifungal shampoo, although this is not explicitly stated. Suggestions on how to do this are not based on clinical trials, but on a review and a textbook of dermatology [Johnson and Nunley, 2000; Plewig and Jansen, 2008].
  • Anti-dandruff shampoos:
    • CKS could find no systematic reviews or good-quality evidence for the use of anti-dandruff shampoos in mild seborrhoeic dermatitis. However, these shampoos are thought to be effective and are recommended in several literature sources [BAD, 2004; Grimalt, 2007].
    • Weak evidence indicates that zinc pyrithione 1% shampoo is effective at reducing the total dandruff severity score, although it is less effective than ketoconazole 2% shampoo [Pierard-Franchimont et al, 2002].
    • In a small open-label trial comparing selenium sulphide 2.5% shampoo and coal tar 2% shampoo, both improved dandruff, folliculitis, pain, and dryness scores [Fredriksson, 1985]. The trial assessed effectiveness using a range of symptoms, and although both products were effective at treating dandruff, coal tar shampoo successfully treated seborrhoea, whereas selenium sulphide aggravated it.
  • Ketoconazole 2% shampoo:
  • Ketoconazole 2% shampoo vs. selenium sulphide 2.5%:
    • Evidence from one RCT [Danby et al, 1993] suggests that both ketoconazole 2% shampoo and selenium sulphide 2.5% shampoo are of similar effectiveness in treating moderate-to-severe dandruff, but more adverse effects occurred in the selenium sulphide group (including pruritus or burning sensation on the scalp and change in hair colour). CKS therefore recommends ketoconazole first-line, as it appears to be better tolerated than selenium sulphide. Both treatments improved symptoms (mean total adherent dandruff severity scores) from day 1 and continued to improve symptoms until day 28.
  • Topical corticosteroid scalp application:
    • A systematic review identified no systematic reviews or RCTs comparing topical corticosteroids (hydrocortisone butyrate, betamethasone valerate, or mometasone furoate) with placebo. However, the authors concluded that there is consensus among specialists that topical corticosteroids are effective in treating seborrhoeic dermatitis of the scalp in adults [Manriquez and Uribe, 2007].
    • Clobetasol propionate is a very potent corticosteroid and is not recommended, as it confers a greater risk of adverse effects.
    • Hydrocortisone butyrate, betamethasone valerate, and mometasone furoate are considered well tolerated in long-term administration, but each carries a risk of local and systemic toxicity following continual use on large areas of damaged skin [ABPI Medicines Compendium, 2005; ABPI Medicines Compendium, 2007; ABPI Medicines Compendium, 2008a].
    • Expert opinion varied with regard to the recommended duration of treatment, but CKS found no evidence for treatment duration and thus has taken the feedback into account when making the recommendation.
  • Symptom control:
    • Some of the literature recommends using antifungal shampoos once a week to prevent the rash from coming back [BAD, 2004].

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