Clinical, Cosmetic and Investigational Dermatology: Published on December 2022

Seborrheic dermatitis (SD) is a common chronic inflammatory skin disorder that most commonly affects young adults, and less often children. In adolescents and adults, SD clinical presentation may range from a mild scalp scaling to diffuse white, yellowish patches in regions rich in sebaceous glands such as scalp, face and trunk. In infants, SD mainly occurs on the scalp as yellowish, scaly patches, with varying degrees of inflammation, configuring the so-called “cradle cap”.

SD pathogenesis is multifactorial and still poorly delineated.

In adults, some environmental triggers (eg, low temperature and humidity in winter) are likely to promote its development, several other factors, including fungal colonization by Malassezia spp. (formerly called Pityrosporum ovale), sebaceous gland activity, as well as immunosuppression, endocrine, neurogenic and iatrogenic factors, have been postulated.

In children, common early occurrence in the first trimester suggests the role of excessive sebaceous gland activity from maternal hormones, along with cutaneous microbiome alterations, including Malassezia spp., Staphylococcus spp., Streptococcus spp., and Corynebacterium spp.

Diagnosis of SD is usually easily made based on past history and typical clinical features. However, in selected cases, especially in more severe and/or recurrent forms, blood tests to rule out HIV infection, nutritional deficiencies, as well as dermatoscopy, useful to identify other dermatoses (eg, psoriasis or tinea capitis), are recommended. 

Treatment Recommendations:

Treatment is aimed at modulating sebum production, reducing skin colonization by Malassezia spp., and controlling inflammation.

In adults, mild-to-moderate scalp SD forms can be managed with topical antifungals (ketoconazole, ciclopirox, miconazole) or antiinflammatory (mild-to-moderate potency corticosteroids) or keratolytic/humectant (propylene glycol) agents.

Recommended topical therapeutic options for mild-to-moderate facial or body areas SD include topical ketoconazole, ciclopirox, clotrimazole, mild-to-moderate potency corticosteroids, lithium succinate/gluconate, and topical calcineurin inihibitors (off-label use).

In severe and/or resistant cases, the use of systemic antifungal drugs (terbinafine, itraconazole), as well as UVB phototherapy, may be considered.

Table Recommended Pharmacological Topical Agents for Scalp Seborrheic Dermatitis in Adults

In children, scant scientific evidence supports the effectiveness and safety of topical drugs, and “cradle cap” is usually successfully managed with baby shampoos enriched with emollient agents and vegetable oils.

Alternatively, similarly to adult scalp SD, medical device shampoos with antiinflammatory and antifungal properties, containing piroctone olamine, bisabolol, alyglicera, telmesteine, may be used.

SD patients should be advised that SD is a chronic disease and therefore a complete resolution after topical or systemic therapy is a difficult goal to achieve. Therefore, due to SD relapsing course, maintenance treatment will often be necessary. Beyond pharmacological treatments, an appropriate cosmetic approach, if correctly prescribed, may improve therapeutic outcomes.