1Division of Dermatology, Department of Medicine, Sunnybrook and Women’s College Health Science Centre (Sunnybrook site) and the University of Toronto, Toronto, Canada
2Mediprobe Research, London, Ontario, Canada
3University of Western Ontario, London, Ontario, Canada
Seborrheic dermatitis is a common inflammatory skin disease, affecting between 1% and 3% of immunocompetent adults. While its cause is unknown, a number of predisposing factors have been reported, including the implications of Malassezia yeasts. Various treatment options are available, such as ciclopirox shampoo, which combines anti-Malassezia activity with an anti-inflammatory action. This agent has been shown to be an effective and safe treatment for seborrheic dermatitis of the scalp.
Key Words: ciclopirox, seborrheic dermatitis
Clinically, seborrheic dermatitis presents as red, flaking, slightly greasy-looking patches, which are located primarily on the scalp, nasolabial folds, ears, eyebrows and chest. The degree of flaking and erythema can vary markedly between patients.1 The exact cause of seborrheic dermatitis is not known, however, a number of predisposing factors have been reported. Such endogenous host factors include nutritional,2 environmental,3,4 and immunological5 factors, as well as the presence of Malassezia yeast.6
While there is some controversy with regard to the relationship between seborrheic dermatitis of the scalp and dandruff, it has been argued that dandruff is a mild form of seborrheic dermatitis.7,8 Furthermore, the relationship between Malassezia yeasts and the effective treatment of seborrheic dermatitis with antifungal agents helps to support the claim that these yeasts are the primary cause of seborrheic dermatitis.9
Due to the fact that there is an increased prevalence of seborrheic dermatitis in HIV-positive and AIDS patients,10,11 it is thought that the disease may be caused by an abnormal immune response to Malassezia. However, it is unclear exactly what this immune response might be. Many individuals without seborrheic dermatitis have antibodies to Malassezia yeasts and while some authors have found that the level of IgG antibodies to the yeasts is increased in patients with seborrheic dermatitis,5,12 others1 have found no difference in the number of antibodies produced by patients with seborrheic dermatitis and controls.
It has recently been suggested that the reaction by seborrheic dermatitis patients to Malassezia is best characterized as an irritant response13 involving an inflammatory reaction and that reduction of Malassezia yeast on the skin reduces the clinical signs of seborrheic dermatitis.
Treating Seborrheic Dermatitis
The two main classes of treatment for seborrheic dermatitis are topical corticosteroids and antifungal agents. Corticosteroids reduce inflammation, thus resulting in clinical improvement of seborrheic dermatitis. However, prolonged treatment with topical steroids may result in adverse effects on the skin, such as atrophy, telangiectasia, or perioral dermatitis14 and, especially in the case of higher potency, fluorinated topical steroids, to dysfunction of the adrenal cortex.15 Because of the adverse effects associated with topical steroids, there has been a shift in treatment strategies for seborrheic dermatitis with an increased interest in antifungal agents. Several antifungal agents have been found to be effective in the treatment of seborrheic dermatitis. These include non-specific agents (e.g., zinc pyrithione, selenium sulfide, propylene glycol, lithium succinate), hydroxypyridones (e.g., ciclopirox), azoles (e.g., bifonazole, fluconazole, itraconazole, ketoconazole, miconazole, metronidazole), and the allylamines (e.g., terbinafine).
Ciclopirox is the ethanolamine salt of 6-cyclohexyl-I-hydroxy-4- methyl-2(IH)-pyridone.16 The empirical formula of ciclopirox is C12H17NO2, with a molecular weight of 207.27.17 Ciclopirox shampoo 1% is a colorless, translucent solution,17 which has been used in the treatment of seborrheic dermatitis. In addition to its effect on Malassezia yeasts, ciclopirox has been shown to decrease inflammation. Rosen et al.18 found that the anti-inflammatory activity of ciclopirox was greater than that of several azole agents or hydrocortisone. Ciclopirox appears to exert its anti-inflammatory effect via several pathways, including the inhibition of 5-lipoxygenase and cyclo-oxygenase.19,20
Clinical Trials of Ciclopirox
Vardy et al.21 conducted a double-blind, randomized, placebocontrolled clinical study of ciclopirox olamine 1% shampoo to determine its effectiveness in the treatment of scalp seborrheic dermatitis. One hundred and two patients were randomly selected to apply either ciclopirox olamine 1% shampoo or the vehicle shampoo to the scalp for 5 minutes, twice per week for 4 weeks. Signs and symptoms of erythema, scaling, and pruritus were assessed at the end of the study, which revealed that 93% of the ciclopirox shampoo-treated patients had significantly improved or cleared compared to 41% in the placebo group (P<0.00001). Another double-blind, randomized, vehicle-controlled study was conducted to assess the efficacy of 1% ciclopirox shampoo in the treatment of seborrheic dermatitis of the scalp.22 Subjects were randomly selected to 5ml (10ml for shoulder-length hair or longer) of either 1% ciclopirox or vehicle shampoo twice per week for 4 weeks. Grading of erythema, scaling, and the overall status of seborrheic dermatitis was performed at week 4, using a 6-point rating scale (0=none, 1=slight, 2=mild, 3=moderate, 4=pronounced, and 5=severe). Effective treatment was defined as a score of 0 (or 1 if baseline score was ≥3) for the combined rating of global status, erythema, and scaling. It was reported that 26% of the ciclopirox-treated patients were effectively treated compared to 13% of the vehicle group (P=0.0001).22
Ciclopirox shampoo 1% was used twice a week in 626 patients.17 Increased itching was the most frequent adverse event found in 1% of the subject population. Furthermore, application reactions, such as burning, erythema, and itching also occurred in 1% of the subjects.17
Dosage and Administration
After wetting hair, apply approximately 1 teaspoon (5ml) of ciclopirox shampoo 1% to the scalp.17 If the patient has long hair, it is recommended to use up to 2 teaspoons (10ml). Lather and leave on for 3 minutes before rinsing. Treatment should be repeated twiceper week for 4 weeks, with a minimum of 3 days between each application.17
Evidence suggests that an abnormal or inflammatory immune system reaction to Malassezia yeasts may be the cause of seborrheic dermatitis. An available treatment for this disease is ciclopirox shampoo, which is an antifungal agent that also has antibacterial and anti-inflammatory properties. The proven efficacy and safety of ciclopirox shampoo in the treatment of seborrheic dermatitis of the scalp makes it an important addition to the treatment options available.
- Parry ME, Sharpe GR. Seborrhoeic dermatitis is not caused by an altered immune response to Malassezia yeast. Br J Dermatol 139(2):254-63 (1998 Aug).
- Brenner S, Horwitz C. Possible nutrient mediators in psoriasis and seborrheic dermatitis. I. Prevalence, etiology, symptomatology, histological and biochemical features. World Rev Nutr Diet 55:153- 64 (1988).
- Liden C, Wahlberg JE. Work with video display terminals among office employees. V. Dermatologic factors. Scand J Work Environ Health 11(6):489-93 (1985 Dec).
- Wahlberg JE, Liden C. Is the skin affected by work at visual display terminals? Dermatol Clin 6(1):81-5 (1988 Jan).
- Bergbrant IM, Johansson S, Robbins D, Scheynius A, Faergemann J, Soderstrom T. An immunological study in patients with seborrhoeic dermatitis. Clin Exp Dermatol 16(5):331-8 (1991 Sep).
- Faergemann J. Seborrhoeic dermatitis and Pityrosporum orbiculare: treatment of seborrhoeic dermatitis of the scalp with miconazolehydrocortisone (Daktacort), miconazole and hydrocortisone. Br J Dermatol 114(6):695-700 (1986 Jun).
- Bulmer AC, Bulmer GS. The antifungal action of dandruff shampoos. Mycopathologia 147(2):63-5 (1999).
- McGrath J, Murphy GM. The control of seborrhoeic dermatitis and dandruff by antipityrosporal drugs. Drugs 41(2):178-84 (1991 Feb).
- Shuster S. The aetiology of dandruff and the mode of action of therapeutic agents. Br J Dermatol 111(2):235-42 (1984 Aug).
- Berger RS, Stoner MF, Hobbs ER, Hayes TJ, Boswell RN. Cutaneous manifestations of early human immunodeficiency virus exposure. J Am Acad Dermatol 19(2 Pt 1):298-303 (1988 Aug).
- Marino CT, McDonald E, Romano JF. Seborrheic dermatitis in acquired immunodeficiency syndrome. Cutis 48(3):217-8 (1991 Sep).
- Midgley G, Hay RJ. Serological responses to Pityrosporum (Malassezia) in seborrhoeic dermatitis demonstrated by ELISA and western blotting. Bull Soc Fr Mycol Med 17:267-76 (1988).
- Faergemann J, Bergbrant IM, Dohse M, Scott A, Westgate G. Seborrhoeic dermatitis and Pityrosporum (Malassezia) folliculitis: characterization of inflammatory cells and mediators in the skin by immunohistochemistry. Br J Dermatol 144(3):549-56 (2001 Mar).
- Guin JD. Complications of topical hydrocortisone. J Am Acad Dermatol 4(4):417-22 (1981 Apr).
- Morman MR. Possible side effects of topical steroids. Am Fam Physician 23(2):171-4 (1981 Feb).
- Sakurai K, Sakaguchi T, Yamaguchi H, Iwata K. Mode of action of 6- cyclohexyl-1-hydroxy-4-methyl-2(1H)-pyridone ethanolamine salt (Hoe 296). Chemotherapy 24(2):68-76 (1978).
- Loprox® Shampoo (ciclopirox) 1% Package Insert. MEDICIS Pharmaceutical Corp., Scottsdale, AZ (2003 Feb).
- Rosen T, Schell BJ, Orengo I. Anti-inflammatory activity of antifungal preparation. Int J Dermatol 36(10):788-92 (1997 Oct).
- Hanel H, Smith-Kurtz E, Pastowsky S. [Therapy of seborrheic eczema with an antifungal agent with an antiphlogistic effect]. Mycoses 34(Suppl 1):91-3 (1991).
- Lassus A, Nolting KS, Savopoulos C. Comparison of ciclopirox olamine 1% cream with ciclopirox 1%-hydrocortisone acetate 1% cream in the treatment of inflamed superficial mycoses. Clin Ther 10(5):594-9 (1988).
- Vardy DA, Zvulunov A, Tchetov T, Biton A, Rosenman D. A doubleblind, placebo-controlled trial of a ciclopirox olamine 1% shampoo for the treatment of scalp seborrheic dermatitis. J Dermatol Treat 11:73-7 (2000).
- Lebwohl M. A multicenter, randomized, double-blind, vehiclecontrolled study of the efficacy and safety of 1% ciclopirox shampoo in the treatment of seborrheic dermatitis of the scalp. Int J Dermatol. In Press (2004).