Seborrheic Dermatitis

Author:
Published: March 30, 2017
Last reviewed: March 31, 2017

What is seborrheic dermatitis?

Seborrheic dermatitis is a common chronic inflammatory skin condition with greasy flakes and redness on the face, scalp or other parts of the body. Seborrheic dermatitis is not an allergy, is not contagious and is not harmful [3].

Dandruff is an uninflamed form of seborrheic dermatitis, which appears as small white flakes on the scalp [6].

Cradle cap is seborrheic dermatitis in infants.

Pityriasiform seborrhoeide is a severe form of seborrheic dermatitis that affects the entire body.

Synonyms: seborrhea, seborrheic eczema, seborrheic psoriasis [6]

Symptoms and Signs

Seborrheic dermatitis can cause one or more of the following symptoms [2,5]:

  • Thick, oily, white, yellowish or grayish scales or plaques
  • Skin redness
  • Red bumps (superficial folliculitis  due to inflammation of the hair follicles)
  • Mild itch or burning feeling
  • Widespread skin reddening and peeling called erythroderma (rare)

Symptoms can last for years and flare and clear without an obvious reason. Commonly affected areas are those with abundant oil glands: the scalp or scalp margin, forehead, eyebrows, eyelids (blepharitis), around the nose (in the nasolabial folds) and behind the ears, ear canal, mustache, beard, armpits, upper central chest, upper back, below the breasts, the belly button, groin, genitals and the area around the anus [2,5,11]. Seborrheic dermatitis does not affect the areas without sebaceous glands, such as the palms and soles [11].

Seborrheic dermatitis on the scalp

Picture 1. Seborrheic dermatitis on the scalp 
(source: DermNet NZ, CC license)

Seborrheic dermatitis on the hairline

Picture 2. Seborrheic dermatitis along the hairline 
(source: Dermatology Atlas)

Seborrheic dermatitis in the eyebrows

Picture 3. Seborrheic dermatitis in the eyebrows 
(source: Dermatology Atlas)

Seborrheic dermatitis behind the ear

Picture 4. Seborrheic dermatitis behind the ear 
(source: avensonline.org, CC license)

Facial seborrheic dermatitis

Picture 5. Seborrheic dermatitis on the face 
(source: OMICS International, CC license)

Seborrheic dermatitis on the chest

Picture 6. Seborrheic dermatitis on the chest (source: Dermatology Atlas)

Seborrheic dermatitis on the upper back

Picture 7. Seborrheic dermatitis on the upper back 
(source: DermNet NZ, CC license)

Seborrheic dermatitis in the armpit

Picture 8. Seborrheic dermatitis in the armpit 
(source: DermNet NZ, CC license)

Causes, Triggers and Risk Factors

Seborrheic dermatitis most commonly appears in infants younger than 3 months and in adults between 30 and 60 years of age [3].

The exact cause is not known; the risk factors can include [3,5,6,7,11,13,14]:

  • Skin scratching and skin disorders, such as acne, rosacea and psoriasis
  • Hereditary factors, such as sensitivity to otherwise normal skin Malassezia yeasts or its product oleic acid, which can result in a break of protective lipid skin barrier
  • Hormonal factors (increased androgen stimulation of the sebaceous glands)
  • Impaired immunity (HIV/AIDS, immunosuppression after organ transplantation)
  • Neurological disorders (Parkinson’s disease, stroke, brain or spinal injury, facial nerve palsy, tardive dyskinesia, epilepsy)
  • Deficiency of nutrients, such as vitamins B2 (riboflavin), B3 (niacin), B6 (pyridoxine), B7 (biotin) or zinc [9], commonly associated with alcoholism and eating disorders
  • Other: obesity, fatigue, lack of sleep, depression, heart attack, congestive heart failure, alcoholic pancreatitis

Emotional stress, cold and dry weather and certain foods and medications (interferon, lithium and psoralen) can trigger a flare of seborrheic dermatitis [1,3].

Seborrheic dermatitis is not a sign of bad personal hygiene [1].

Differential Diagnosis

Conditions that may look similar to seborrheic dermatitis [7,9,11,18]:

  • Allergic and irritant contact dermatitis
  • Cutaneous candidiasis
  • Psoriasis vulgaris (sharply demarcated silvery white scales on the scalp, nail pitting)
  • Rosacea (redness, but no scales, on the cheeks and nose)
  • Systemic lupus erythematosus or SLE (red “butterfly rash” without scales on the cheeks and forehead, swollen joints)
  • Tinea infection or ringworm (alopecia: focal hair loss with broken hair)
  • Erythrasma (red or brown patches in the armpits, groin or skin folds)
  • Skin rash associated with a gastrointestinal disease, such as Crohn’s disease
  • In children:
    • Atopic dermatitis or eczema (very itchy scaly red rash on the scalp, forehead or face in infants)
    • Impetigo (crusty red rash on the face due to a staph infection)

Treatment

The treatment, which includes anti-dandruff shampoos or antifungal and steroid ointments, can decrease the growth of the skin yeasts, remove scales and decrease itch. It is a dermatologist who can suggest which products to use and for how long. Treatment usually lasts for at least a month.

Outdoor activities with exposure to sun can decrease symptoms [5].

Treatment of Mild Seborrheic Dermatitis on the SCALP

There is MODERATE EVIDENCE that anti-dandruff shampoos, foams, lotions or sprays containing antifungals ketoconazole or ciplopirox [8,11,26,27] or steroids [11,27] can be effective in the treatment of the mild seborrheic dermatitis.

Treatment of Mild Seborrheic Dermatitis on the FACE

There is MODERATE EVIDENCE about the effectiveness of following in the treatment of the mild seborrheic dermatitis on the face:

  • Antifungal creams or gels containing ketoconazole, ciplopirox or naftifin [8,9,11,19,21,23,26,27]
  • Steroid creams containing hydrocortisone, betamethasone dipropionate, fluocinolone acetonide or desonide [11,19,23,26]. A common side effect with long-term (several weeks) use is thinning of the skin [19].
  • Topical lithium gluconate or succinate [23,26]
  • Immunomodulators pimecrolimus and tacrolimus (for persistent dermatitis; can cause hypopigmentation in black persons) [23,24,26,27]

Avoid products that contain alcohol, which irritates the skin. Petroleum jelly (soft paraffin) is not recommended [4].

Treatment of Moderate to Severe Seborrheic Dermatitis

Oral antifungals, such as itraconazole was effective in some studies [11,28,29].

Oral isotretinoin reduces inflammation and oil production by the sebaceous glands; it can be used when other therapy does not help [22].

Treatment Options with Insufficient Evidence of Effectiveness

There is insufficient evidence about the effectiveness of the following in the treatment of seborrheic dermatitis:

  • Keratolytics and antifungals: azelaic acid [20], salicylic acid (with or without sulfur) pine tar, propylene glycol, urea, benzoyl-peroxide, zinc pyrithion or selenium sulfide [27]
  • Moisturizers (emollients), including shea butter [25,27]
  • Essential oils: aloe vera, arnica, jojoba, olive, peanut or mineral oil, tea tree oil [10,12]
  • Supplements: vitamins B2, B3, B6 or C, fish oil
  • Drugs: metronidazole (an oral antibiotic) [11,21], terbinafine (an antifungal) [25,27], fluocinonide (a steroid), antihistamines, antiandrogens (cyproterone acetate, spironolactone and flutamide [15,16])
  • Phototherapy with UV-B light
  • Dead sea salt
  • Acupuncture

Prevention

  • Avoid scratching.
  • If you have a beard, shave it off.
  • Do not use hair pomades.
  • Wear loose smooth cloths to avoid irritation.
  • Reference: 17, 19

Seborrheic Dermatitis in Infants

In infants, seborrheic dermatitis on the scalp is called cradle cap. The condition, which can also affect the diaper area or other parts of the skin, does not cause itch, is not dangerous and usually spontaneously disappear between the 6th and 12th month of life [1].

Seborrheic dermatitis (cradle cap) in an infant

Picture 9. Seborrheic dermatitis (cradle cap) on the head of an infant (source: DermNet NZ, CC license)

Severe seborrheic dermatitis in an infant

Picture 10. Severe seborrheic dermatitis in an infant (source: DermNet NZ, CC license)

Treatment includes baby shampoo and if this does not help, anti-dandruff shampoo. Before shampooing, you can apply warm mineral oil to soften the large thick scales.

Frequently Asked Questions?

1. How often should you wash hair with anti-dandruff shampoo?

If you have seborrheic dermatitis, you should wash hair according to instruction on the shampoo bottle or doctor’s recommendation. It is usually recommended to wash hair every day or every other day and for black persons once a week [4].

2. Does seborrheic dermatitis cause hair loss?

No [11]. Focal hair loss typically occurs in a fungal infection Tinea capitis (scalp ringworm).

  • References

      1. Seborrheic dermatitis  American Academy of Dermatology
      2. Seborrheic dermatitis, symptoms  American Academy of Dermatology
      3. Seborrheic dermatitis, causes  American Academy of Dermatology
      4. Seborrheic dermatitis, tips  American Academy of Dermatology
      5. Johnson BA et al, 2000, Teatment of seborrheic dermatitis  American Family Physician
      6. Seborrheic dermatitis DermNet NZ
      7. Seborrheic dermatitis: an overview  American Family Physician
      8. Okokon EO et al, 2015, Topical antifungals for seborrhoeic dermatitis  PubMed
      9. Sampio ALSB et al, 2011, Seborrheic dermatitis  SciELO
      10. Satchell AC et al, 2002, Treatment of dandruff with 5% tea tree oil shampoo  PubMed
      11. Borda LJ et al, 2015, Seborrheic Dermatitis and Dandruff: A Comprehensive Review  PubMed Central
      12. Pazyar N et al, 2013, A review of applications of tea tree oil in dermatology  PubMed
      13. Hoffman K, 2015, When Vitamin And Nutritional Deficiencies Cause Skin And Nail Changes  Podiatry Today
      14. Seborrheic dermatitis risk factors  Mayo Clinic
      15. Zouboulis CC et al, 2004, Androgen action on human skin — from basic research to clinical significance  PubMed
      16. Singh SM et al, 2000, Androgen receptor antagonists (antiandrogens): structure-activity relationships  PubMed
      17. Seborrheic dermatitis lifestyle and home remedies  Mayo Clinic
      18. Handler MZ, Seborrheic dermatitis differential diagnosis  Emedicine
      19. Handler MZ, Seborrheic dermatitis treatment  Emedicine
      20. Bikowski J, 2009, Facial seborrheic dermatitis: a report on current status and therapeutic horizons  PubMed
      21. Apasrawirote W et al, 2011, Topical antifungal agents for seborrheic dermatitis: systematic review and meta-analysis  PubMed
      22. de Souza Leão Kamamoto C et al, 2017, Low-dose oral isotretinoin for moderate to severe seborrhea and seborrheic dermatitis: a randomized comparative trial  PubMed
      23. 2015, Topical anti?inflammatory agents for seborrhoeic dermatitis of the face or scalp  PubMed Health
      24. Ang-Tiu CU et al, 2012, Pimecrolimus 1% cream for the treatment of seborrheic dermatitis: a systematic review of randomized controlled trials  PubMed
      25. Manríquez JJ et al, 2007, Seborrheic dermatitis  PubMed Central
      26. Gupta AK et al, 2017, Topical Treatment of Facial Seborrheic Dermatitis: A Systematic Review  PubMed
      27. Del Roso JQ, 2011, Adult seborrheic dermatitis  PubMed Central
      28. Goldenberg G, 2013, Optimizing Treatment Approaches in Seborrheic Dermatitis  PubMed Central
      29. Ghotsi SZ et al, 2015, Efficacy of Oral Itraconazole in the Treatment and Relapse Prevention of Moderate to Severe Seborrheic Dermatitis: A Randomized, Placebo-Controlled Trial  PubMed
      30. Stefanaki I et al, 2010, Therapeutic Update on Seborrheic Dermatitis  Skin Therapy Letter

Leave a Reply

Your email address will not be published. Required fields are marked *