• Scenario: Seborrhoeic dermatitis - scalp and beard: covers what advice to give, how to manage seborrhoeic dermatitis of the scalp and beard areas, and when to follow up or refer.
• Scenario: Seborrhoeic dermatitis - face and body: covers what advice to give, how to manage seborrhoeic dermatitis of the face and body, and when to follow up or refer.
• Scenario: Seborrhoeic dermatitis - infants: covers what advice to give parents, how to manage seborrhoeic dermatitis in infants, and when to follow up and refer.
• Scenario: Seborrhoeic dermatitis - severe or widespread: covers the management of people with more severe and widespread seborrhoeic dermatitis.

• 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.

In depth

• 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.

In depth

• 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.

In depth

• 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.

In depth

• Consider referral to a dermatologist if there is:
• Diagnostic uncertainty.
• Failure to respond to routine treatment.
• Severe or widespread seborrhoeic dermatitis.

In depth

• 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.

In depth

• 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.

In depth

• 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.

In depth

• 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.

In depth

• 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).

In depth

• 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.

In depth

• If simple measures are not effective, prescribe ketoconazole 2% cream once a day (or other topical imidazole). Ketoconazole shampoo is another 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.

In depth

• 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.

In depth

• 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.

In depth

• 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).

In depth

• Consider whether the diagnosis of seborrhoeic dermatitis is correct 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.

In depth