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What's the Best Treatment for Cradle Cap?

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What's the Best Treatment for Cradle Cap? From the CLINIcAL InQUiRiES Family Physicians Inquiries Network Ryan C. Sheffield, MD, Paul Crawford, MD What’s the best treatment Eglin Air Force Base Family Medicine Residency, Eglin Air for cradle cap? Force Base, Fla Sarah Towner Wright, MLS University of North Carolina at Chapel Hill Evidence-based answer Ketoconazole (Nizoral) shampoo appears corticosteroids to severe cases because to be a safe and efficacious treatment of possible systemic absorption (SOR: C). for infants with cradle cap (strength of Overnight application of emollients followed recommendation [SOR]: C, consensus, by gentle brushing and washing with usual practice, opinion, disease-oriented baby shampoo helps to remove the scale evidence, and case series). Limit topical associated with cradle cap (SOR: C). ® Dowden Health Media Clinical commentary ICopyrightf parents can’t leave it be, recommend brush to loosen the scale. Although mineral oil andFor a brush personal to loosen scale use noonly evidence supports this, it seems safe Cradle cap is distressing to parents. They and is somewhat effective. want everyone else to see how gorgeous This review makes me feel more FAST TRACK their new baby is, and cradle cap can make comfortable with recommending ketocon- their beautiful little one look scruffy. My azole shampoo when mineral oil proves If parents need standard therapy has been to stress to the insufficient. For resistant cases, a cute hat to do something, parents that it isn’t a problem for the baby. can work wonders. If the parents still want to do something recommend Valerie J. King, MD, MPH applying mineral about it, I recommend mineral oil and a soft Oregon Health Sciences University, Portland oil and brushing to loosen z Evidence summary scales followed by gentle brushing and the scale Cradle cap is a form of seborrheic der- washing with baby shampoo is an accept- matitis that manifests as greasy patches ed treatment, although no trials could be of scaling on the scalp of infants be- found to show its efficacy for infants.1,3 tween the second week and sixth month Numerous treatments for seborrheic of life.1,2 Untreated, it usually resolves at dermatitis with proven efficacy for adults 8 months.1 It’s generally nonpruritic and have been adopted for use for infants. doesn’t bother the infant, though it can be These include topical antifungals, anti- a stressor for parents.1 dandruff shampoos with zinc pyrithione Researchers have noted a potential or selenium sulfide, coal tar preparations, link with increased concentrations of the and episodic topical corticosteroids.1,4 yeast Malassezia furfur (formerly Pityros- Although each of these agents is used for porum ovale), but a causative mechanism infants with cradle cap, significantly sized has not been identified.1,2 Overnight use randomized controlled trials in this age of emollients such as mineral oil to soften group are essentially absent. 232 VOL 56, NO 3 / MARCH 2007 THE JOURNAL OF FAMILY PRACtICE For mass reproduction, content licensing and permissions contact Dowden Health Media. What’s the best treatment for cradle cap? Although limited evidence exists for scale with mineral oil, followed by gentle seborrhea treatment in any age group, ke- brushing and shampooing is an alterna- toconazole shampoo appears to be backed tive approach. Ketoconazole 2% sham- by the strongest evidence. For example, an poo or cream once a day has been shown uncontrolled multicenter trial with 575 to be effective; PRODIGY recommends adults found ketoconazole shampoo was avoiding topical corticosteroids.1 superior to placebo for treatment of scalp A review article recommends daily seborrheic dermatitis with an 88% “excel- shampooing with an unmedicated sham- lent response” rate (P<.0001, no relative poo. If this doesn’t work, the authors rec- risk or confidence intervals given).4 ommend trying a dandruff shampoo and Based on small studies, ketoconazole softening the scales with mineral oil be- appears safe and effective for infants. A fore washing.8 While the American Acad- small (n=13) phase I safety trial of infants emy of Dermatology has no official guide- demonstrated that ketoconazole shampoo lines on this subject, their patient-oriented applied twice weekly for 1 month resulted pamphlet Dermatology Insights suggests in no detectable serum ketoconazole levels that “cradle cap is treated with anti-dan- or elevation in liver function tests.5 In an- druff or baby shampoo, with or without other small (n=19) uncontrolled study of hydrocortisone lotion or cream, depend- once-daily ketoconazole 2% cream, 79% ing on the severity.”9 n of infants affected with seborrheic derma- titis of the scalp and diaper area showed Acknowledgments good response by day 10 (no statistical The opinions and assertions contained herein are the private views of the authors and not to be construed methods reported). Peak plasma ketocon- as official, or as reflecting the views of the US Air Force azole levels in this study were only 1% to Medical Service or the US Air Force at large. 2% of those documented after systemic administration.6 References Studies conducted on topical steroids 1. PRODIGY [database]. Seborrhoeic dermatitis. Knowledge Guidance structured review (2006). Sow- have also shown weak data. An unblinded erby Centre for Health Informatics at Newcastle Ltd uncontrolled comparative study of 2% ke- (SCHIN). Available at: www.prodigy.nhs.uk/sebor- FAST TRACK toconazole cream and 1% hydrocortisone rhoeic_dermatitis. Accessed on February 6, 2007. Systemic cream in the treatment of infantile sebor- 2. Wannanukul S, Chiabunkana J. Comparative study of 2% ketoconazole cream and 1% hydrocortisone absorption— rheic dermatitis revealed no statistical dif- cream in the treatment of infantile seborrheic dermati- ference (31% vs 35%) in severity for 48 tis. J Med Assoc Thai 2004; 87:S68–S71. and, sometimes, 3. Janniger CK. Infantile seborrheic dermatitis: An ap- infants. All skin lesions in both treatment proach to cradle cap. Cutis 1993; 51:233–235. adenocortical groups were cleared by the end of the sec- 4. Peter RU, Richarz-Barthauer U. Successful treatment suppression—are ond week of treatment.2 and prophylaxis of scalp seborrhoeic dermatitis and dandruff with 2% ketoconazole shampoo: results of a an issue with mild Multiple authors note safety concerns multicentre, double-blind, placebo-controlled trial. Br when considering treatment for mild and J Dermatol 1995; 132:441–445. topical steroids self-limited conditions such as cradle cap. 5. Brodell R, Patel S, Venglarick J, Moses D, Gemmel in children Several studies have demonstrated system- D. The safety of ketoconazole shampoo for infantile seborrheic dermatitis. Pediatr Dermatol 1998; 15:406– ic absorption and, in some cases, adreno- 407. cortical suppression when using mild topi- 6. Taieb A, Legrain V, Palmier C, Lejean S, Six M, Mal- cal steroids such as 1% hydrocortisone eville J. Topical ketoconazole for infantile seborrhoeic dermatitis. Dermatologica 1990; 181:26–32. 1,3,7 cream in pediatric populations. 7. Turpeinen M, Salo O, Leisti S. Effect of percutaneous absorption of hydrocortisone on adrenocortical re- Recommendations from others sponsiveness in infants with severe skin disease. Br J Dermatol 1986; 115:475–484. The guidance from PRODIGY (the UK’s 8. Seborrhea: What it is and how to treat it. Am Fam Phy- National Health Service primary care sician 2000; 61:2173–2174. database) recommends regular washing 9. When to be concerned about childhood hair shedding. Dermatology Insights 2003; 4(1):24. Available at: www. with baby shampoo followed by gentle aad.org/NR/rdonlyres/0AA67E605-01E104C7A- brushing. Alternatively, softening the B493-9959923A8282/0/di_spring03.pdf#page=24. Accessed on February 6, 2007. www.jfponline.com VOL 56, NO 3 / MARCH 2007 233.
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