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Seborrhoeic dermatitis - Management
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Overview of management
- The management of seborrhoeic dermatitis depends on the person's age, the severity of the condition, and its distribution.
- The key features of management are:
- Offer advice on self-care measures.
- Prescribe appropriate topical treatments if self-care measures have not provided sufficient improvement.
- For adults, once symptoms are controlled, consider maintenance treatment to minimize recurrences.
- Follow up if response to treatment is inadequate, symptoms worsen despite treatment, or signs of infection develop.
- Refer or seek specialist advice if the diagnosis is uncertain, the condition is severe or widespread, primary care treatment has been unsuccessful, or the eyelid area is involved and simple eyelid hygiene measures have been ineffective.
Seborrhoeic dermatitis of the scalp and beard
What advice should I give?
- Reassure the person that seborrhoeic dermatitis is not caused by lack of cleanliness or excessive dryness of the skin, and is not transmissable.
- Explain that treatment cannot cure seborrhoeic dermatitis but can control it. Symptoms often recur after treatment has stopped.
- Avoid using cosmetic products that contain alcohol.
- Avoid using soap and shaving cream on the face if they cause irritation. Advise the use of non-greasy emollients or emollient soap substitutes.
- A diet rich in yeast-containing products will not affect the disease. If the person has known dietary triggers, these should be avoided, and if the diet is generally poor, advise an improved diet.
- Advise stress reduction, if possible.
Basis for recommendation
- The recommendation about lack of cleanliness not causing seborrhoeic dermatitis is based on a review of the management of seborrhoeic dermatitis [Gupta and Bluhm, 2004].
- Treatment is suppressive rather than curative, and as such, seborrhoeic dermatitis often comes back after treatment has stopped. Treatment may have to be used for months or even years [BAD, 2004; NGC, 2007].
- Cosmetic products containing alcohol solutions usually aggravate the inflammatory state and should be avoided [Selden, 2007; Plewig and Jansen, 2008].
- Soap and shaving cream may be irritating when applied to affected skin. Emollients or emollient soap substitutes can be used instead [Plewig and Jansen, 2008].
- CKS could find no evidence that dietary factors contribute to seborrhoeic dermatitis. Stress may aggravate it [Schwartz et al, 2006].
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].
What maintenance treatment is recommended?
- If relapse is a problem, advise use of an antifungal shampoo once a week, or once every other week, or according to the manufacturer's instructions.
- Topical corticosteroids are not appropriate for continuous long-term use, and their use as maintenance treatment is not recommended.
Basis for recommendation
- A patient information leaflet from the British Association of Dermatologists recommends using antifungal shampoos once a week to prevent the rash coming back [BAD, 2004].
- CKS could find no systematic reviews of measures to prevent recurrence of seborrhoeic dermatitis. Evidence from a double-blind, placebo controlled trial supports the use of ketoconazole 2% shampoo once weekly to prevent seborrhoeic dermatitis of the scalp [Peter and Richarz-Barthauer, 1995].
- Continuous long-term use of topical steroids increases the risk of local and systemic adverse reactions [ABPI Medicines Compendium, 2005; ABPI Medicines Compendium, 2007; ABPI Medicines Compendium, 2008a], and in the absence of supporting evidence, their use is not recommended.
How should I follow up?
- Routine follow up is not usually required.
- Advise the person to seek further medical advice if:
- Response to treatment is poor.
- Symptoms worsen despite treatment.
- Signs of infection (e.g. crusting, oozing, bleeding) develop.
Basis for recommendation
- CKS could find no guidelines or evidence on the follow up of seborrhoeic dermatitis of the scalp and beard, and thus have made these pragmatic recommendations.
When should I refer?
- Consider referral to a dermatologist if there is:
- Diagnostic uncertainty.
- Failure to respond to routine treatment.
- Severe or widespread seborrhoeic dermatitis.
Basis for recommendation
- CKS found no referral guidelines for seborrhoeic dermatitis of the scalp and beard.
- The recommendation to refer if there is diagnostic uncertainty or the person is not responding to topical treatment is supported by a review of the treatment of seborrhoeic dermatitis [Johnson and Nunley, 2000].
- The recommendation to refer if seborrhoeic dermatitis is severe or widespread is pragmatic advice. For more information, see Managing severe or widespread seborrhoeic dermatitis.
Seborrhoeic dermatitis of the face and body
What advice should I give?
- Reassure the person that seborrhoeic dermatitis is not caused by lack of cleanliness or excessive dryness of the skin, and is not transmissable.
- Explain that treatment cannot cure seborrhoeic dermatitis but can control it. Symptoms often recur after treatment has stopped.
- Avoid using cosmetic products that contain alcohol.
- Avoid using soap and shaving cream on the face if they cause irritation. Advise the use of non-greasy emollients or emollient soap substitutes.
- A diet rich in yeast-containing products will not affect the disease. If the person has known dietary triggers, these should be avoided, and if the diet is generally poor, advise an improved diet.
- Advise stress reduction, if possible.
Basis for recommendation
- The recommendation about lack of cleanliness not causing seborrhoeic dermatitis is based on a review of the management of seborrhoeic dermatitis [Gupta and Bluhm, 2004].
- Treatment is suppressive rather than curative, and as such, seborrhoeic dermatitis often recurs after treatment has stopped. Treatment may have to be used for months or even years [BAD, 2004; NGC, 2007].
- Cosmetic products containing alcohol solutions usually aggravate the inflammatory state and should be avoided [Selden, 2007; Plewig and Jansen, 2008].
- Soap and shaving cream may be irritating when applied to affected skin. Emollients or emollient soap substitutes can be used instead [Plewig and Jansen, 2008].
- CKS could find no evidence that dietary factors contribute towards seborrhoeic dermatitis. Stress may aggravate it [Schwartz et al, 2006].
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].
What maintenance treatment is recommended?
- Wash the affected area with ketoconazole 2% shampoo or apply ketoconazole 2% cream (or other topical imidazole) weekly or every other week (depending on the frequency of recurrence).
- Avoid using topical corticosteroids for maintenance treatment.
Basis for recommendation
- CKS could find no good-quality evidence on maintenance treatment for seborrhoeic dermatitis of the face and body. Therefore, the recommendation to use ketoconazole shampoo has been extrapolated from advice and evidence on maintenance treatment for seborrhoeic dermatitis of the scalp. Feedback from an expert reviewer suggested that topical ketoconazole cream 2% is also appropriate.
- The British Association of Dermatologists advises people to continue with an antifungal shampoo once weekly to prevent recurrence of seborrhoeic dermatitis of the scalp [BAD, 2004]:
- A double-blind, placebo-controlled trial provides evidence to support the prophylactic use of antifungal treatments to reduce the relapse rates of seborrhoeic dermatitis of the scalp [Peter and Richarz-Barthauer, 1995].
- Although no similar studies were found examining prophylactic treatment of the face and body, this seems logical.
How should I follow up?
- Routine follow up is not usually required.
- Advise the person to seek further medical advice if:
- Response to treatment is poor.
- Symptoms worsen despite treatment.
- Signs of infection (e.g. crusting, oozing, bleeding) develop.
Basis for recommendation
- CKS could find no guidelines or evidence on the follow up of seborrhoeic dermatitis, and thus have made these pragmatic recommendations.
When should I refer?
- Consider referral to a dermatologist if there is:
- Diagnostic uncertainty.
- Failure to respond to routine treatment.
- Severe or widespread seborrhoeic dermatitis.
- Eyelid involvement (where simple eyelid hygiene measures have been unsuccessful).
Basis for recommendation
- CKS found no referral guidelines for seborrhoeic dermatitis.
- The recommendation to refer if there is diagnostic uncertainty or the person is not responding to topical treatment is supported by a review of the treatment of seborrhoeic dermatitis [Johnson and Nunley, 2000].
- The recommendation to refer if seborrhoeic dermatitis is severe or widespread is pragmatic advice. For more information, see Managing severe or widespread seborrhoeic dermatitis.
Seborrhoeic dermatitis in infants
What should I advise?
- Reassure the parents that infantile seborrhoeic dermatitis is not a serious condition, does not usually trouble the infant, and will spontaneously resolve within weeks to a few months.
- Try simple measures. Suggested methods include:
- Regular washing of the scalp with a baby shampoo, followed by gentle brushing with a soft brush to loosen scales and improve the condition.
- Softening the scales with baby oil first, followed by gentle brushing, then washing off with baby shampoo.
- Soaking the crusts overnight with white petroleum jelly or a slightly warmed vegetable or olive oil, and shampooing in the morning.
- If these methods do not achieve softening, a greasy emollient or soap substitute, such as emulsifying ointment, can be used, which helps to remove the scales more easily.
Basis for recommendation
How should I treat?
- If simple measures (see Advice) are not effective, prescribe ketoconazole 2% cream once a day (or other topical imidazole). Ketoconazole shampoo is an alternative option:
- Treat until symptoms resolve. If symptoms persist longer than 4 weeks with treatment, seek specialist advice.
- Topical corticosteroids are not usually advised, although they may be of use for certain infants with nappy rash. For more information, see the CKS topic on Nappy rash.
Basis for recommendation
- Advice regarding simple measures was available in peer-reviewed journals, although not systematically reviewed [Janniger, 1993; O'Connor et al, 2008; Plewig and Jansen, 2008].
- Ketoconazole 2% cream once a day has been shown to be effective for infantile seborrhoeic dermatitis in a small open-label study [Taieb et al, 1990]. Studies of percutaneous absorption in seven infants showed minimal plasma levels, despite the large surface area of topical application [Levron and Taieb, 1991]:
- CKS has extrapolated evidence from ketoconazole to apply to other imidazole creams on the basis of feedback from expert reviewers and their similar safety profiles in terms of absorption.
- CKS could find no trial evidence for ketoconazole shampoo, but expert feedback and a review article suggest it as an option [O'Connor et al, 2008].
- CKS could find no evidence for the duration of topical ketoconazole treatment. CKS suggests treating until symptoms resolve but seeking specialist advice if symptoms persist beyond 4 weeks, as the diagnosis may need to be reconsidered. This takes into account feedback from expert reviewers and information from the manufacturers [ABPI Medicines Compendium, 2008c].
- CKS could find no systematic reviews of the safety and effectiveness of topical corticosteroids in infants. The available evidence regarding the use of topical corticosteroids in infants was of low quality. There is concern about systemic absorption in paediatric populations compared with topical ketoconazole [Sheffield et al, 2007].
How should I treat recurrence?
- Use clinical judgement depending on the overall duration and appearance of the rash, bearing in mind that seborrhoeic dermatitis in infants usually resolves spontaneously:
- If confident that the diagnosis is correct, consider repeating a course of treatment.
- If the diagnosis is uncertain, seek specialist advice.
Basis for recommendation
- CKS could find no systematic reviews of the treatment of recurrent episodes of seborrhoeic dermatitis in infants.
- Infantile seborrhoeic dermatitis usually resolves within several weeks to several months [O'Connor et al, 2008]. Because the condition is self limiting and the course is generally short, CKS does not recommend prophylactic measures, but suggests reviewing the diagnosis if symptoms persist.
When should I follow up?
- Routine follow up is not usually required.
- Advise seeking further medical advice if:
- Response to treatment is poor.
- Symptoms worsen despite treatment.
- Signs of infection (e.g. crusting, oozing, bleeding) develop.
Basis for recommendation
- CKS could find no guidelines or evidence on the follow up of seborrhoeic dermatitis in infants, and thus have made these pragmatic recommendations.
When should I refer?
- Consider referral to a dermatologist if there is:
- Diagnostic uncertainty.
- Failure to respond to routine treatment.
- Severe or widespread seborrhoeic dermatitis.
- Eyelid involvement (where simple eyelid hygiene measures have been unsuccessful).
Basis for recommendation
- CKS found no referral guidelines for seborrhoeic dermatitis in infants.
- The recommendation to refer if there is diagnostic uncertainty or the person is not responding to topical treatment is supported by a review of the treatment of seborrhoeic dermatitis [Johnson and Nunley, 2000].
- The recommendation to refer if seborrhoeic dermatitis is severe or widespread is pragmatic advice. For more information, see Managing severe or widespread seborrhoeic dermatitis.
How should I manage severe or widespread seborrhoeic dermatitis?
- Consider whether the diagnosis of seborrhoeic dermatitis is correct (see Differential diagnosis) and whether the person may be immunocompromised (e.g. HIV infection):
- Consider blood tests based on clinical judgement (e.g. full blood count, glucose measurement, viral serology).
- Refer to a dermatologist and seek specialist advice as to whether treatment is needed while the person is waiting to be seen.
Basis for recommendation
- The recommendation to refer if seborrhoeic dermatitis is severe or widespread is based on the concern that people with severe seborrhoeic dermatitis are more likely to have an underlying immunodeficiency than people with milder or localized rash:
- Some authors believe that, in people with HIV, seborrhoeic dermatitis is more severe than usual [Gupta and Bluhm, 2004].
- Generalized seborrhoeic dermatitis is uncommon in otherwise healthy children and usually is associated with immunodeficiency [Schwartz et al, 2006].
- Several treatments have been suggested for widespread seborrhoeic dermatitis or cases that are refractory to topical treatments (e.g. oral antifungal drugs [Gupta and Bluhm, 2004; Plewig and Jansen, 2008]). Because of the potentially serious adverse effects of these treatments, CKS recommends seeking specialist advice in this situation to ensure that the diagnosis is correct and appropriate treatment is initiated.
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