Photo RoUNDS Anna K. Allred, BS; Nancye K. McCowan, Adolescent with rash on face MS, MD; Robert Brodell, MD University of Mississippi and scalp Medical Center (Ms. Allred); Division of Dermatology, University What was causing a hypopigmented, slightly scaly facial of Mississippi Medical Center, Jackson (Drs. rash and dandruff in this otherwise healthy teenager? McCowan and Brodell); University of Rochester School of Medicine and Dentistry, NY (Dr. Brodell) A 13-year-old African American male popigmentation in the nasomesial folds and [email protected] presented with a 2-year history of a mildly eyebrows, and diffuse scaling and erythema DEpartment EDItOR pruritic central facial rash (FIGURE) and dan- throughout his scalp. Richard p. Usatine, MD druff. Recent treatment with hydrocortisone University of Texas 1% cream and nystatin cream (100,000 U/gm) Health Science Center at San Antonio for 1 week resulted in no improvement. ● What is youR diAgnosis? The patient had no history to suggest an Ms. Allred and Dr. McCowan allergic contact dermatitis or drug allergy. He ● HoW Would you TReAT THIS reported no potential conflict of interest relevant to this article. had confluent scaling and erythema with hy- pATIENT? Dr. Brodell serves on speaker’s bureaus for Allergan, Galderma, and PharmaDerm, has served as a consultant and on advisory Figure boards for Galderma, and is an investigator/received grant/research support from Slight scale and hypopigmentation in the nasomesial folds Genentech. PHO T o COU RT ESY OF : R o B e RT BR ODELL , MD jfponline.com Vol 63, no 4 | ApRIL 2014 | The jouRnAl of Family PracTice 209 PHOTO RoUNDS Diagnosis: the Malassezia yeast and topical steroids are Seborrheic dermatitis used to suppress inflammation. Azole anti- Seborrheic dermatitis (SD) is a chronic der- fungal medications such as ketoconazole are matitis caused by Malassezia yeast species, in- effective and can be used for long periods of cluding Malassezia (Pityrosporum ovale).1 SD time with minimal risk of adverse effects3-5 affects 1% to 3% of the general population in (strength of recommendation [SOR]: C). the United States and has 2 incidence peaks: Our patient had used nystatin cream, which the first occurs during infancy and the second is effective against Candida yeast infections, but between 30 to 50 years of age.2 The abnormal not especially effective forMalassezia sp.6 response to the yeast organism leads to inflam- z to reduce inflammation, mild topical mation, proliferation, and desquamation.2 steroids such as hydrocortisone cream 2.5% The diagnosis of SD is made based on should be used. However, they must be used the presence of sharply marginated scaled for short periods to avoid atrophy, telangiec- patches in areas with a high concentration tasias, and steroid-induced acne. An alterna- of sebaceous glands including the scalp, eye- tive evolving treatment is to use a calcineurin brows, and nasomesial folds. Pruritus, ery- inhibitor, such as pimecrolimus cream 1% thema, and greasy scales also are commonly or tacrolimus ointment 0.1%. These drugs seen.3 Raised lateral margins reminiscent of do not exacerbate hypopigmentation, an ef- the advancing border of dermatophyte infec- fect that sometimes is attributed to topical there is no tions and postinflammatory hypopigmenta- steroids.7 cure for tion may also be present in African American Scalp treatments include shampoos seborrheic patients. Both of these findings in the na- such as ketoconazole 2%, selenium sulfide dermatitis, so somesial folds, eyebrows, and scalp led to the 2.5%, and ciclopirox 1%.3 Shampoos should the goal of diagnosis of SD in this patient. be lathered up and left on the scalp for 3 to treatment is 5 minutes before rinsing. to control the dermatitis. Differential diagnosis includes two forms of ketoconazole psoriasis, lichen simplex chronicus for our patient The differential for dandruff includes psoria- Our patient responded well to ketoconazole sis, as well as lichen simplex chronicus and cream 2% applied twice daily to the face and tinea capitis. Psoriasis often is associated other areas without hair and ketoconazole 2% with thicker, white micaceous scaling. The shampoo twice weekly. At a 6-week follow- latter 2 conditions would not produce the up, the patient had significant improvement symmetrical scaling in nasomesial folds that in scaling and pruritus on the central face and we saw with our patient. scalp. The associated facial hypopigmenta- SD in the central face can appear similar tion faded over 3 months. JFP to pityriasis versicolor, allergic contact derma- titis, and irritant dermatitis (pityriasis alba), CORRESpONDENCE Robert T. Brodell md, division of dermatology, university of but these conditions are not associated with mississippi medical center, 2500 north state street, jackson, diffuse dandruff. ms 39216; [email protected] Strength of recommendation (SOR) Antifungals are the mainstay A Good-quality patient-oriented evidence of treatment B Inconsistent or limited-quality Because there is no cure for SD, the goal of patient-oriented evidence therapy is to control the dermatitis. Topi- C Consensus, usual practice, opinion, cal antifungal agents are used to suppress disease-oriented evidence, case series References 1. Nakabayashi A, Sei Y, Guillot J. Identification of Malassezia atopic dermatitis, pityriasis versicolor and normal subjects. species isolated from patients with seborrhoeic dermatitis, Med Mycology. 2000;38:337-341. 210 The jouRnAl of Family PracTice | ApRIL 2014 | Vol 63, no 4 rAsh on face And scalp 2. Sampaio AL, Mameri AC, Vargas TJ, et al. Seborrheic dermati- Topical antifungal agents for seborrheic dermatitis: systematic tis. An Bras Dermatol. 2011;86:1061-1071;quiz 1072-1074. review and meta-analysis. J Med Assoc Thai. 2011;94:756-760. 3. Naldi L. Seborrhoeic dermatitis. Clin Evid (Online). 6. Pedrosa AF, Lisboa, C, Rodrigues AG. Malassezia infections: A 2010;2010:pii:1713. medical conundrum. J Am Acad Dermatol. 2014 Feb 22. Epub 4. Draelos ZD, Feldman SR, Butners V, et al. Long-term safety of ahead of print. ketoconazole foam, 2% in the treatment of seborrheic derma- 7. High WA, Pandya AG. Pilot trial of 1% pimecrolimus cream in titis: results of a phase IV, open-label study. J Drugs Dermatol. the treatment of seborrheic dermatitis in African American 2013;12:e1-e6. adults with associated hypopigmentation. J Am Acad Derma- 5. Apasrawirote W, Udompataikul M, Rattanamongkolgul S. tol. 2006;54:1083-1088. New name, same valuable source of pain management information For information on pain management, go to our Web site at www.currentpainperspectives.com and check out these articles: n Diagnosing fibromyalgia and myofascial pain syndrome: A guide n Neurogenic thoracic outlet syndrome: Often overlooked, but treatable n How best to prevent acute pain from becoming chronic? jfponline.com Vol 63, no 4 | ApRIL 2014 | The jouRnAl of Family PracTice 211.