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Seborrheic : An Overview ROBERT A. SCHWARTZ, M.D., M.P.H., CHRISTOPHER A. JANUSZ, M.D., and CAMILA K. JANNIGER, M.D. University of Medicine and Dentistry at New Jersey-New Jersey Medical School, Newark, New Jersey

Seborrheic dermatitis affects the , central , and anterior chest. In adolescents and adults, it often presents as scalp scaling (). Seborrheic dermatitis also may cause mild to marked of the nasolabial fold, often with scaling. can cause flare-ups. The scales are greasy, not dry, as commonly thought. An uncommon generalized form in may be linked to immunodeficiencies. Topical therapy primarily consists of agents and low-potency . New topical calcineurin inhibitors (immunomodulators) sometimes are administered. (Am Fam Physician 2006;74:125-30. Copyright © 2006 American Academy of Family Physicians.)

eborrheic dermatitis can affect patients levels, fungal infections, nutritional deficits, from infancy to old age.1-3 The con- neurogenic factors) are associated with the dition most commonly occurs in condition. The possible hormonal link may infants within the first three months explain why the condition appears in infancy, S of life and in adults at 30 to 60 years of age. In disappears spontaneously, then reappears adolescents and adults, it usually presents as more prominently after . A more scalp scaling (dandruff) or as mild to marked causal link seems to exist between seborrheic erythema of the nasolabial fold during times dermatitis and the proliferation of of stress or sleep deprivation. The latter type species (e.g., , Malassezia tends to affect men more often than women ovalis) found in normal dimorphic human and often is precipitated by emotional stress. flora.6-8 Yeasts of this genus predominate and An uncommon generalized form in infants are found in seborrheic regions of the body may be linked to immunodeficiencies. that are rich in sebaceous lipids (e.g., head, Seborrheic dermatitis and capitis trunk, upper back). A causal relationship is () are common in early childhood. implied because of the ability to isolate Mal- According to one survey of 1,116 children,4 assezia in patients with seborrheic dermatitis the overall age- and sex-adjusted prevalence and by its therapeutic response to antifungal of seborrheic dermatitis was 10 percent in agents.9 A similar link has been suggested in boys and 9.5 percent in girls. The highest studies of patients with seborrheic dermatitis prevalence occurred in the first three months that is associated with acquired immunodefi- of life, decreasing rapidly by one year of age, ciency syndrome (AIDS).10,11 Seborrheic der- and slowly decreasing over the next four matitis also may be associated with nutritional years.4 Most patients (72 percent) had mini- deficiencies, but there is no firm linkage. mal to mild seborrheic dermatitis. Pityriasis An altered pattern may capitis occurred in 42 percent of the children be important in the pathogenesis of infan- examined (86 percent had a minimal to mild tile seborrheic dermatitis. Serum essential case).4 Prevalence estimates for older persons fatty acid patterns from 30 children with the are consistently higher than estimates for the condition suggested a transient impaired general population.5 function of the delta-6 desaturase enzyme.12 A neurogenic theory for the development Etiology of seborrheic dermatitis may account for its Despite the high prevalence of seborrheic association with parkinsonism and other dermatitis, little is known about its etiol- neurologic disorders, including postcerebro- ogy. However, several factors (e.g., hormone vascular accidents, epilepsy, central nervous

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Evidence Clinical recommendation rating References

Infants with generalized seborrheic dermatitis, diarrhea, and C 14 failure to thrive should be evaluated for immunodeficiencies. The first-line therapy for seborrheic dermatitis of the scalp should C 2, 20, 34 be topical steroids. Topical calcineurin inhibitors (e.g., ointment [Protopic], B 26-28 cream [Elidel]) are recommended for seborrheic dermatitis of the face and ears. Once-daily (Nizoral) combined with two weeks of B 22 once-daily (Desowen) is recommended for seborrheic dermatitis of the face.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 17 or http://www.aafp.org/afpsort.xml.

system trauma, facial nerve palsy, and syrin- Classification gomyelia induced by neuroleptic drugs with Adolescent and adult seborrheic dermatitis extrapyramidal effects.7 It may be confined usually starts as mild greasy scaling of the to the syringomyelia-affected area or to the scalp with erythema and scaling of the naso- paralyzed side in a patient with hemiplegia. labial folds (Figure 1) or the postauricular However, no neurotransmitters have been skin. The scaling often is concurrent with identified in this context. an oily complexion and appears in areas of increased activity (e.g., auricles, beard area, , trunk [flexure and inframammary areas; Figure 2]). Some- times the central face is involved (Figure 3). , with meibomian gland occlusion and abscess formation, , and coexistent vulgaris or pityriasis versi- color, may be evident. Two types of seborrheic dermatitis may appear on the chest—a common petaloid type and a rarer pityriasiform type.2 The former starts as small, reddish-brown follic- ular and perifollicular with greasy Figure 1. Nasolabial fold scaling and ery­ scales. These papules become patches that thema from seborrheic dermatitis. resemble the shape of flower petals or a medallion (medallion seborrheic dermati- tis). The pityriasiform type often has gen- eralized macules and patches that resemble extensive . These patches rarely produce an eruption so generalized that it causes erythroderma. In infants, seborrheic dermatitis may pres- ent as thick, greasy scales on the vertex of the scalp (cradle cap).2,3 The condition is not pruritic in infants, as it is in older children and adults. Typically, acute dermatitis (char- acterized by oozing and weeping) is absent. The scales may vary in color, appearing Figure 2. Severe persistent seborrheic dermatitis of the inframam­ white, off-white, or yellow. Infants with large, mary folds. dry scales often have psoriasiform seborrheic

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table 1 of Seborrheic Dermatitis

Atopic dermatitis Candidiasis histiocytosis Rosacea Systemic erythematosus Tinea infection

children and adults (Figure 4). Highly active antiretroviral therapy may reduce incidence in patients with AIDS. Psoriasis vulgaris may be difficult to distin- guish from seborrheic dermatitis. Psoriasis vulgaris of the scalp presents as sharply demarcated scalp plaques. Other signs of psoriasis, such as nail pitting or distal ony- 16,17 Figure 3. Central facial erythema from sebor­ cholysis, also may facilitate distinction. rheic dermatitis. Seborrheic dermatitis also may resemble , , and, rarely, dermatitis. This presentation often is the only cutaneous or Langerhans cell sign of seborrheic dermatitis in infants and histiocytosis. Atopic dermatitis in adults usually occurs in the third or fourth week characteristically appears in antecubital and after birth. However, the scalp, central face, popliteal fossae. Tinea capitis, tinea faciei, forehead, and ears may have fine, widespread scaling. The dermatitis may become gener- alized. The flexural folds may be involved, often with a cheesy exudate that manifests as a diaper dermatitis that also may become gen- eralized. Generalized seborrheic dermatitis is uncommon in otherwise healthy children and usually is associated with immunode- ficiencies. Immunocompromised children with generalized seborrheic dermatitis often have concomitant diarrhea and failure to thrive5-8 (Leiner’s disease); therefore, infants with these symptoms should be evaluated for immunodeficiencies.13-15

Differential Diagnosis A number of disorders are similar to seb- orrheic dermatitis (Table 1). One study11 showed that 47 percent of patients with AIDS had recalcitrant eruptions similar to sebor- Figure 4. Generalized seborrheic dermatitis-like eruption associated rheic dermatitis that may be generalized in with acquired immunodeficiency syndrome.

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and tinea corporis may have hyphae on are a nonspecific finding. Rarely, infants potassium hydroxide cytologic examination; are affected by histologic-specific scaling, candidiasis produces pseudohyphae. Sebor- seborrheic dermatitis-like eruptions on the rheic dermatitis of the groin may resemble scalp with fever, and other systemic signs of dermatophytosis, psoriasis, candidiasis, acute Langerhans cell histiocytosis (Letterer- and, sometimes, Langerhans cell histiocyto- Siwe disease). Scabetic eczema occasionally sis. Rosacea may produce a facial erythema resembles widespread seborrheic dermatitis. resembling seborrheic dermatitis. Although Riboflavin, , and pyridoxine deficien- rosacea tends to include central facial ery- cies have been associated with seborrheic thema, it may involve only the forehead. dermatitis-like eruptions in infants.19 Con- Infants may have atopic dermatitis that is comitant disorders (e.g., psoriasis, scabetic prevalent in certain body areas (e.g., scalp, eczema, superficial fungal infection) may face, diaper areas, extensor limb surfaces), complicate seborrheic dermatitis, especially suggesting seborrheic dermatitis.18 However, in patients with AIDS. in infants, seborrheic dermatitis has axil- lary patches, lacks oozing and weeping, and Histology lacks pruritus. The distinction is a clinical Skin biopsies may effectively distinguish seb- one because elevated orrheic dermatitis from similar disorders. (IgE) levels associated with atopic dermatitis Seborrheic dermatitis should have neutro- phils in the scale crust at the margins of follicular ostia. AIDS-associated seborrheic table 2 dermatitis more commonly presents as para- Therapies for Treating Seborrheic Dermatitis keratosis, a few individually necrotic kera- tinocytes within the , and plasma Therapy Usage cells in the dermis. Yeast cells sometimes are visible within on special stains. Anti-inflammatory If hyphae are present, dermatomycosis is the (immunomodulatory) agents diagnosis. Shorter hyphae with spores (“spa- ghetti and meatball pattern”) are present Fluocinolone (Synalar) Two times per week with .8 Topical steroids Fluocinolone Daily Treatment valerate (Beta-Val) Daily Effective therapies for seborrheic dermatitis Desonide cream (Desowen) Daily include anti-inflammatory (immunomodu- Topical calcineurin inhibitors latory) agents, agents, , Tacrolimus ointment (Protopic)* Daily and alternative (Table 2).1-3,20-37 Pimecrolimus cream (Elidel)* Daily anti-inflammatory shampoo Two times per week (immunomodulatory) agents Tar shampoo Three times per week The conventional treatment for adult sebor- shampoo (also has Two times per week rheic dermatitis of the scalp starts with topi- antifungal properties) cal steroids or a calcineurin inhibitor. These Antifungals therapies may be administered as a shampoo, Ketoconazole shampoo (Nizoral) Three times per week such as fluocinolone (Synalar), topical ste- sulfide shampoo (Selsun) Two times per week roid solutions, applied to the scalp, 30,31,34-36 Alternative or creams applied to the skin. Adults shampoo Daily with seborrheic dermatitis typically use topi- cal steroids once or twice daily, often in *—Off-label use. addition to a shampoo. Low-potency topical Information from references 1 through 3 and 20 through 37. steroids may effectively treat infantile or adult seborrheic dermatitis of the flexural areas or

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persistent recalcitrant seborrheic dermatitis alternative medications in adults.2,20 A topical azole preparation may Natural therapies are becoming increasingly be combined with a desonide regimen (one popular. Tea tree oil (Melaleuca oil) is an dose daily for two weeks) for facial seborrheic essential oil from a shrub native to Aus- dermatitis.22 tralia. The therapy appears to be effective Topical calcineurin inhibitors (e.g., tacro- and well tolerated when used daily as a limus ointment [Protopic], pimecrolimus 5 % shampoo.25 cream [Elidel]) have fungicidal and anti- inflammatory properties without the risk of The Authors cutaneous atrophy, which is associated with topical steroids.26-28 Calcineurin inhibitors ROBERT A. SCHWARTZ M.D., M.P.H., is professor and head of and professor of medicine, pediat- also are good therapies when the face and rics, pathology, and preventive medicine and community ears are affected. However, one week of daily at the University of Medicine and Dentistry of New use is necessary before benefits are apparent. Jersey (UMDNJ)-New Jersey Medical School, Newark. He received a medical degree from New York Medical College keratolytics in Manhattan and completed a residency at the University of Cincinnati College of Medicine, Ohio, and at Roswell Older modalities for treating seborrheic der- Park Cancer Institute, Buffalo, N.Y. He is a member of matitis may have had keratolytic but not spe- American Family Physician’s editorial advisory board. 1,2 cific antifungal properties. Keratolytics that CHRISTOPHER A. JANUSZ, M.D., is resident physician are widely used to treat seborrheic dermatitis at New York Medical College. He received a medical include tar, salicylic acid, and degree from Jagiellonian University School of Medicine in Cracow, Poland. . Pyrithione zinc has nonspecific keratolytic and antifungal properties3,21 and CAMILA K. JANNIGER, M.D., is clinical professor and chief of pediatric dermatology and geriatric dermatology at can be applied two or three times per week. the UMDNJ-New Jersey Medical School. She received a Patients should leave these shampoos on the medical degree from the Medical Academy of Warsaw in hair for at least five minutes to ensure that it Poland. Dr. Janniger completed an internship at the Albert reaches the scalp. Patients also may use it on Einstein College of Medicine of the Yeshiva University’s Montefiore Medical Center, Bronx, N.Y., and a dermatol- other affected sites, such as the face. Infantile ogy residency at the UMDNJ-New Jersey Medical School. seborrheic dermatitis of the scalp requires a gentle approach3 (e.g., a mild, nonmedicated Address correspondence to Robert A. Schwartz, M.D., M.P.H., UMDNJ-New Jersey Medical School, Dept. of shampoo). Dermatology, 185 S. Orange Ave., Newark, NJ 07103 (e-mail: [email protected]). Reprints are not antifungals available from the authors. Most antifungal agents attack Malassezia The authors dedicate this paper to Decio Cerimele, M.D., associated with seborrheic dermatitis.1,2 A professor and chair of dermatology at the University of once-daily ketoconazole gel preparation Sassari in Italy, and to Francesca Cerimele, M.D., University of Alabama Huntsville Family Medicine Residency. (Nizoral) combined with a two-week, once- daily regimen of desonide (Desowen), may Author disclosure: Nothing to disclose. be useful for facial seborrheic dermatitis.22 Shampoos containing selenium sulfide (Sel- REFERENCES sun) or an azole often are used.1,2,20,21 These 1. Gupta AK, Madzia SE, Batra R. Etiology and manage- shampoos can be applied two or three times ment of seborrheic dermatitis. Dermatology 2004; per week. Ketoconazole (cream or foaming 208:89-93. gel)31,32 and oral terbinafine (Lamisil) also 2. Janniger CK, Schwartz RA. Seborrheic dermatitis may be beneficial.23 Other topical antifungal [Published correction appears in Am Fam Physician 1995;52:782]. Am Fam Physician 1995;52:149-55, 33,36 agents include (Loprox) and 159-60. 29 fluconazole (Diflucan). Patients also may 3. Janniger CK. Infantile seborrheic dermatitis: an use a 2 % ketoconazole or a fluconazole approach to cradle cap. Cutis 1993;51:233-5. shampoo.29,30,35 Some azoles (e.g., itracon- 4. Foley P, Zuo Y, Plunkett A, Merlin K, Marks R. The fre- quency of common skin conditions in preschool-aged azole [Sporanox], ketoconazole) also have children in Australia: seborrheic dermatitis and pityriasis anti-inflammatory properties.37 capitis (cradle cap). Arch Dermatol 2003;139:318-22.

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5. Mastrolonardo M, Diaferio A, Vendemiale G, Lopalco P. placebo-controlled study of ketoconazole + desonide in the elderly: inferences on the gel combination in the treatment of facial seborrheic possible role of disability and loss of self-sufficiency. dermatitis. Dermatology 2002;204:344-7. Acta Derm Venereol 2004;84:285-7. 23. Cassano N, Amoruso A, Loconsole F, Vena GA. Oral 6. Mastrolonardo M, Diaferio A, Logroscino G. Seborrheic terbinafine for the treatment of seborrheic dermatitis dermatitis, increased sebum excretion, and Parkinson’s in adults. Int J Dermatol 2002;41:821-2. disease: a survey of (im)possible links. Med Hypotheses 24. Taieb A, Legrain V, Palmier C, Lejean S, Six M, Maleville 2003;60:907-11. J. Topical ketoconazole for infantile seborrheic dermati- 7. Piérard GE. Seborrheic dermatitis today, gone tomor- tis. Dermatologica 1990;181:26-32. row? The link between the biocene and treatment. 25. Satchell AC, Saurajen A, Bell C, Barnetson RS. Treat- Dermatology 2003;206:187-8. ment of dandruff with 5% tea tree oil shampoo. J Am 8. Schwartz RA. Superficial fungal infections. Lancet Acad Dermatol 2002;47:852-5. 2004;364:1173-82. 26. Meshkinpour A, Sun J, Weinstein G. An open pilot study 9. Heng MC, Henderson CL, Barker DC, Haberfelde G. using tacrolimus ointment in the treatment of sebor- Correlation of Pityosporum ovale density with clinical rheic dermatitis. J Am Acad Dermatol 2003;49:145-7. severity of seborrheic dermatitis as assessed by a simpli- 27. Szepietowski J. Pimecrolimus: a new treatment for fied technique. J Am Acad Dermatol 1990;23:82-6. seborrheic dermatitis. J Eur Acad Dermatol Venereol 10. Dunic I, Vesic S, Jevtovic DJ. Oral candidiasis and seb- [in press]. orrheic dermatitis in HIV-infected patients on highly 28. Rigopoulos D, Ioannides D, Kalogeromitros D, Grego- active antiretroviral therapy. HIV Med 2004;5:50-4. riou S, Katsambas A. Pimecrolimus cream 1% vs. beta- 11. Wiwanitkit V. Prevalence of dermatological disorders methasone 17-valerate 0.1% cream in the treatment in Thai HIV-infected patients correlated with different of seborrhoeic dermatitis. A randomized open-label CD4 lymphocyte count statuses: a note on 120 cases. clinical trial. Br J Dermatol 2004;151:1071-5. Int J Dermatol 2004;43:265-8. 29. Rigopoulos D, Katsambas A, Antoniou C, Theocharis S, 12. Tollesson A, Frithz A, Berg A, Karlman G. Essential Stratigos J. Facial seborrheic dermatitis treated with flu- fatty acids in infantile seborrheic dermatitis. J Am Acad conazole 2% shampoo. Int J Dermatol 1994;33:136-7. Dermatol 1993;28:957-61. 30. Squire RA, Goode K. A randomised, single-blind, 13. Sonea MJ, Moroz BE, Reece ER. Leiner’s disease associ- single-centre clinical trial to evaluate comparative clini- ated with diminished third component of complement. cal efficacy of shampoos containing ciclopirox olamine Pediatr Dermatol 1987;4:105-7. 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Infantile psoriasis. Cutis matitis: a multicentre, randomized study. Br J Dermatol 2005;76:173-7. 2003;148:1230-6. 18. Turner D, Schwartz RA. Atopic dermatitis: a clinical 33. Baysal V, Yildirim M, Ozcanli C, Ceyhan AM. Itracon- challenge. Acta Dermatovenerol Alp Panonica Adriat azole in the treatment of seborrheic dermatitis: a new [in press]. treatment modality. Int J Dermatol 2004;43:63-6. 19. Brenner S, Horwitz C. Possible nutrient mediators in 34. Milani M, Antonio Di Molfetta S, Gramazio R, Fiorella C, psoriasis and seborrheic dermatitis. II. Nutrient media- Frisario C, Fuzio E, et al. Efficacy of betamethasone valer- tors: essential fatty acids; A, E and D; vitamins ate 0.1% thermophobic foam in seborrhoeic dermatitis B1, B2, B6, and biotin; C selenium; zinc; of the scalp: an open-label, multicentre, prospective trial iron. World Rev Nutr Diet 1988;55:165-82. on 180 patients. Curr Med Res Opin 2003;19:342-5. 20. Faergemann J. Seborrhoeic dermatitis and Pityrospo- 35. Zeharia A, Mimouni M, Fogel D. Treatment of bifon- rum orbiculare: treatment of seborrhoeic dermatitis azole shampoo for scalp seborrhea in infants and young of the scalp with miconazole- (Dakta- children. Pediatr Dermatol 1996;13:151-3. cort), miconazole and hydrocortisone. Brit J Dermatol 36. Lebwohl M, Plott T. Safety and efficacy of ciclopirox 1986;114:695-700. 1% shampoo for the treatment of seborrheic derma- 21. Piérard-Franchimont C, Goffin V, Decroix J, Piérard GE. titis of the scalp in the U.S. population: results of a A multicenter randomized trial of ketoconazole 2% and double-blind, vehicle-controlled trial. Int J Dermatol zinc pyrithione 1% shampoos in severe dandruff and 2004;43(suppl 1):S17-20. seborrheic dermatitis. Skin Pharmacol Appl Skin Physiol 37. Reichrath J. Antimycotics: why are they effective in 2002;15:434-41. the treatment of seborrheic dermatitis? Dermatology 22. Piérard-Franchimont C, Piérard GE. A double-blind 2004;208:174-5.

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