Seborrheic Dermatitis: New Formulations for Treatment

Janet G. Hickman, MD
Dermatology Consultants, Inc. and the Education & Research Foundation, Inc. Lynchburg, VA, USA

Seborrheic dermatitis is a common cutaneous disorder occurring in at least 3%–5% of the population.¹ Dandruff, the less inflammatory form of seborrheic dermatitis, occurs in 50%–80% of teenagers and adults.²

Diagnosis

Seborrheic dermatitis is diagnosed clinically by observing:

• Oily flaking
• Erythema
• Occurrence in characteristic locations
• Scalp
• Creases around the nose
• Glabellar crease
• Behind the ears
• In eyebrows, beard, or moustache
• Midsternum

There may be symptoms of:

• Itching
• Burning
• Stinging

There are no diagnostic or necessary laboratory tests and biopsy is seldom needed.

Clinical Course

In infancy, seborrheic dermatitis presents as “cradle cap”— thick yellow flaking at the vertex of the scalp. It may also cause diaper dermatitis in infants and intertriginous rash in infants and adults. Seborrheic dermatitis is absent in the preadolescent child but recurs after puberty. The course is usually chronic and intermittent with flares induced by:

• Stress
• Temperature and humidity changes
• Changes in general health
• Changes in skin care

Seborrheic Dermatitis in Systemic Disease

Worsening of seborrheic dermatitis is a common finding in Parkinson’s disease and related neurological conditions. Pronounced seborrheic dermatitis is one of the earliest and most common findings in HIV/AIDS, even in the era of highly active antiretroviral therapy (HAART).³

Differential Diagnosis

Etiology

While the detailed pathophysiology of seborrheic dermatitis remains to be clarified, the following are involved:

• Malassezia (formerly called Pityrosporum) yeasts
• Sebum
• Hereditary propensity

Sebum is necessary to support the growth of Malassezia. Although Malassezia yeasts are common colonizers of most adult scalps, only some individuals develop the flaking and inflammatory response of seborrheic dermatitis. The frequency of positive family histories implies a genetic component to the propensity to develop seborrheic dermatitis. The exact mechanism by which Malassezia yeasts induce inflammation is not fully understood. Lipases created by the organism produce free fatty acids such as oleic acid from sebum. Experimentally, application of oleic acid to scalps of susceptible individuals can mimic the scaling and erythema of seborrheic dermatitis.1 Other proposed mechanisms of inflammation initiation are alternative complement activation and Toll-like Receptor (TLR) stimulation by Malassezia.

Treatment approaches include:

• Sebum removal
• Use of anti-Malassezia agents
• Use of anti-inflammatory agents

Sebum Removal

Many patients mistakenly believe the flaking of their face or scalp is “dry skin”; they need to be encouraged to shampoo regularly and use gentle but effective facial cleansers. Greasy and oily face and scalp products can aggravate the condition and should be avoided. It is especially important for African-American patients to find suitable scalp products; newer gel formulations of medications for seborrheic dermatitis may successfully replace greasy pomades.

Topical Agents

• Anti-Malassezia: Several of the anti-Malassezia agents are available by prescription for the treatment of seborrheic dermatitis.4 These include:
• Ketoconazole 2% gel (Xolegel™) (FDA approved July 2006)
• q.d. for 2 wks
• anhydrous gel formulation with propylene glycol
• Ketoconazole 2% cream (Nizoral^® , generic)
• b.i.d. for 4 weeks
• Ciclopirox 0.77% cream, gel, suspension (Loprox^®,generic)
• b.i.d. for 4 weeks
• Sulfacetamide 10% cream, foam, gel, wash (Ovace™)
• b.i.d. for 8-10 days
• Sulfacetamide/sulfur suspension, cream, emulsion, gel, wash (Plexion^®, Rosac^®, Rosanil^®, Rosula^®, generic)
1-3 times daily

Vehicle choice is important as the poor barrier function of skin with active seborrheic dermatitis makes it prone to stinging or burning. Propylene glycol containing nonalcohol gels (or anhydrous gels) are well tolerated and have the advantage of being acceptable for hairy areas, e.g., the beard, as they do not leave a residue. Additionally, the use of the anhydrous gel formulation eliminates the potential for adverse effects associated with sodium sulfite-containing cream. Some cream formulas cake on the skin accentuating the flaking, whereas ointments may be too greasy.

• Anti-inflammatory: Topical low- and mid-potency corticosteroids may be helpful for brief intermittent use, but the chronic nature of seborrheic dermatitis makes dependence on steroids inadvisable because of the risks of developing skinatrophy, steroid rosacea, dyspigmentation, and absorption.

To avoid steroid side-effects, the topical calcineurin inhibitors tacrolimus5 (Protopic^® ointment) and pimecrolimus6 (Elidel^® cream) have been used off-label for seborrheic dermatitis.

Treatment Shampoos for Seborrheic Dermatitis and Dandruff

First-line treatment includes the use of an antiseborrheic (antidandruff) shampoo. The scalp is a reservoir for Malassezia; regular use of a treatment shampoo improves long-term control. Dandruff shampoos depend on the anti-Malassezia efficacy of the following active ingredients:7,8

Non-prescription:

• Ketoconazole 1% (Nizoral A-D^®)
• Pyrithione zinc (ZPT) 0.3%–2% (Head and Shoulders^®, Zincon^®, DHS^® zinc)
• Selenium sulfide 0.6%–1% (Selsun Blue^®, Head and Shoulders^® Intensive Treatment)
• Coal tar 0.5%–5% (T-Gel^®, Denorex^®, Polytar^®, XSebT^®, DHS^® tar, Ionil^® T)
• Sulfur 2%–5% (Meted^®)

Prescription:

• Ketoconazole 2% (Nizoral^®, generic)
• Selenium sulfide 2.5% (Selsun^®, generic)
• Ciclopirox 1% (Loprox^®)

In general, the efficacy of these active ingredients parallels their anti-Malassezia potency. Note that formulation also makes a difference to efficacy, with micro-dispersed ZPT or selenium sulfide more effective than standard formulas. The incorporation of non-oily conditioners into some antidandruff products makes them more acceptable cosmetically. The addition of menthol can give some short-term itch relief. Salicylic acid, urea, or glycolic acid may assist scale removal. Among herbal products, tea tree oil has shown some efficacy against Malassezia.^9,10

Editor's Commentary

Seborrheic dermatitis is a common problem of variable severity which prominently affects the facial skin and scalp surface. Although Dr. Hickman rightly asserts that a biopsy is rarely needed to establish the diagnosis, some degree of medical investigation may be warranted. Ninety to ninety-five percent of those with HIV infection and some 35% of those afflicted with neurological disorders (such as, but not limited to, Parkinson’s Disease) will develop seborrheic dermatitis.1 Hereditary or acquired zinc deficiency may present as seborrheic dermatitis; psoriasis and rosacea may overlap clinically with it; and facial dermatophytosis may closely mimic it.2 Drugs, including gold derivatives, anabolic steroids, cimetidine, psoralens, and some psychotropic agents may induce seborrheic dermatitis.³ Acute onset seborrheic dermatitis may be a sign of eating disorders, such as occult anorexia nervosa or bulimia.⁴

Because we do not really know the cause of seborrheic dermatitis, we treat a number of putative etiologic factors. This explains why such diverse drugs as anti-inflammatory agents (corticosteroids and topical calcineurin inhibitors), keratolytics (salicylic acid) and anti-fungal agents (ketoconazole and ciclopirox) may be of benefit. Tachyphylaxis is not rare, and therefore periodic rotation of therapeutic agents may be necessary.⁵ This is particularly evident when treating scalp disease with shampoo products.

As is true of many rosacea patients, those with seborrheic dermatitis are more susceptible to cutaneous irritation.⁶ This is especially true on the face. Therefore, it is wise to consider the formulation of potential treatment modalities. The newest ketoconazole product is supplied in a rapidly vanishing and well-tolerated anhydrous gel formulation which also has the advantage of once-daily use.

References

1. Gupta AK, Batra R, Bluhm R, Boekhout T, Dawson TL Jr. Skin diseases associated with Malassezia species. J Am Acad Dermatol 51(5):785-98 (2004 Nov).
2. Hickman JG, Wang X, King B, et al. Dandruff part I: scalp disease prevalence in Caucasians, African-Americans and Chinese and the effects of shampoo frequency on scalp health. Presented at: the American Academy of Dermatology Meeting, New Orleans, LA, 2002.
3. Zancanaro PC, McGirt LY, Mamelak AJ, Nguyen RH, Martins CR. Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: An institutional urban clinical experience. J Am Acad Dermatol 54(4):581-8 (2006 Apr).
4. Elewski B, Ling MR, Phillips TJ. Efficacy and safety of a new once-daily topical ketoconazole 2% gel in the treatment of seborrheic dermatitis: A Phase III trial. J Drugs Dermatol 5(7):646-50 (2006 Jul-Aug).
5. Meshkinpour A, Sun J, Weinstein G. An open pilot study using tacrolimus ointment in the treatment of seborrheic dermatitis. J Am Acad Dermatol 49(1):145-7 (2003 Jul).
6. High WA, Pandya AG. Pilot trial of 1% Pimecrolimus cream in the treatment of seborrheic dermatitis in African American adults with associated hypopigmentation. J Am Acad Dermatol 54(6):1083-8 (2006 Jun).
7. Schwartz JR, Cardin CW, Dawson TL. Dandruff and Seborrheic Dermatitis. In: Barran, R and Maibach, HI, Eds. Textbook of Cosmetic Dermatology, 3rd Ed. Taylor and Francis: New York (2005) pp. 259-272.
8. Billhimer WL, Bryant PB, Murray KP, et al. Results of clinical trial comparing 1% pyrithione zinc and 2% ketoconazole shampoos. Cosmetic Dermatol 9(5):34-9 (1996).
9. Weseler A, Geiss HK, Saller, Reichling J. Antifungal effect of Australian tea tree oil on Malassezia pachydermatis isolated from canines suffering from cutaneous skin disease. Schweiz Arch Tierheilkd 144(5):215-21 (2002 May).
10. Hammer KA, Carson CF, Riley TV. In vitro activities of ketoconazole, econazole, miconazole, and Melaleuca alternifolia (tea tree) oil against Malassezia species. Antimicrob Agents Chemother 44(2):467-9 (2000 Feb).

Editorial References

1. Abdulla FR, Brodell RT. Seborrheic dermatitis. The link between facial rash and neurologic disease. Postgrad Med 117(3):43-4 (2005 Mar).
2. Gorani A, Oriani A, Cambiaghi S. Seborrheic dermatitis-like tinea faciei. Pediatr Dermatol 22(3):243-4 (2005 May-Jun).
3. Scheinfeld NS. Seborrheic dermatitis. Skinmed 4(1):49-50 (2005 Jan-Feb).
4. Strumia R. Dermatologic signs in patients with eating disorders. Am J Clin Dermatol 6(3):165-73 (2005).
5. Gupta AK, Kogan N. Seborrhoeic dermatitis: current treatment practices. Expert Opin Pharmacother 5(8):1755-65 (2004 Aug).
6. Cowley NC, Farr PM. A dose-response study or irritant reactions to sodium lauryl sulphate in patients with seborrhoeic dermatitis and atopic eczema. Acta Derm Venereol 72(6):432-5 (1992 Nov).

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