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Dermatitis, Seborrheic
Juan Qiu, MD, PhD
image BASICS
Chronic, superficial, recurrent inflammatory rash affecting sebum-rich, hairy regions of the body, especially the scalp, eyebrows, and face
  • Predominant age: infancy, adolescence, and adulthood
  • Predominant sex: male > female
Seborrheic dermatitis: 3-5%
  • Skin surface yeasts Malassezia (formerly Plasmodium ovale) may be a contributing factor (1,2).
  • The mite Demodex folliculorum may have a direct/indirect role (3).
  • Genetic and environmental factors: Flares are common with stress/illness.
  • Parallels increased sebaceous gland activity in infancy and adolescence or as a result of some acnegenic drugs.
  • Seborrheic dermatitis is more common in immunosuppressed patients, suggesting that immune mechanisms are implicated in the pathogenesis of the disease, although the mechanisms are not well defined (1).
Positive family history; no genetic marker is identified to date.
  • Parkinson disease
  • AIDS (disease severity correlated with progression of immune deficiency)
  • Emotional stress
  • Medications may flare/induce seborrheic dermatitis: auranofin, aurothioglucose, buspirone, chlorpromazine, cimetidine, ethionamide, gold, griseofulvin, haloperidol, interferon-&agr;, lithium, methoxsalen, methyldopa, phenothiazine, psoralen, stanozolol, thiothixene, trioxsalen (2)
Seborrheic skin should be washed more often than usual.
  • Parkinson disease
  • AIDS
Diagnosis of seborrheic dermatitis usually can be made by history and physical exam.
  • Scalp appearance varies from mild, patchy scaling to widespread, thick, adherent crusts. Plaques are rare.
  • Seborrheic dermatitis can spread onto the forehead, the posterior part of the neck, and the postauricular skin, as in psoriasis.
  • Skin lesions manifest as brawny or greasy scaling over red, inflamed skin.
  • Hypopigmentation is seen in African Americans.
  • Infectious eczematoid dermatitis, with oozing and crusting, suggests secondary infection.
  • Seborrheic blepharitis may occur independently.
  • Atopic dermatitis: Distinction may be difficult in infants.
  • Psoriasis
    • Usually knees, elbows, and nails are involved.
    • Scalp psoriasis will be more sharply demarcated than seborrhea, with crusted, infiltrated plaques rather than mild scaling and erythema.
  • Candida
  • Tinea cruris/capitis: Suspect these when usual medications fail/hair loss occurs.
  • Eczema of auricle/otitis externa
  • Rosacea
  • Discoid lupus erythematosus: Skin biopsy will be beneficial.
  • Histiocytosis X: may appear as seborrheic-type eruption
  • Dandruff: scalp only, noninflammatory
Diagnostic Procedures/Other
Consider biopsy if
  • Usual therapies fail
  • Petechiae is noted.
  • Histiocytosis X is suspected.
  • Fungal cultures in refractory cases or when pustules and alopecia are present.
Test Interpretation
Nonspecific changes
  • Hyperkeratosis, acanthosis, accentuated rete ridges, focal spongiosis, and parakeratosis are characteristic.
  • Parakeratotic scale around hair follicles and mild superficial inflammatory lymphocytic infiltrate
  • Increase frequency of shampooing.
  • Sunlight in moderate doses may be helpful.
  • Cradle cap
    • Frequent shampooing with a mild, nonmedicated shampoo
    • Remove thick scale by applying warm mineral oil, then wash off 1 hour later with a mild soap and a soft-bristle toothbrush or terrycloth washcloth.
  • Adults: Wash all affected areas with antiseborrheic shampoos. Start with over-the-counter products (selenium sulfide) and increase to more potent preparations (containing coal tar, sulfur, or salicylic acid) if no improvement is noted.
  • For dense scalp scaling, 10% liquor carbonic detergens in Nivea oil may be used at bedtime, covering the head with a shower cap. This should be done nightly for 1 to 3 weeks.

First Line
  • Cradle cap: Use a coal tar shampoo or ketoconazole (Nizoral) shampoo if the nonmedicated shampoo is ineffective.
  • Adults
    • Topical antifungal agents
      • Ketoconazole or miconazole 2% shampoo twice a week for clearance, then once a week or every other week for maintenance (1,4,5,6)[A] Ketoconazole (Nizoral) and sertaconazole 2% cream may be used to clear scales in other areas (1,4,5,6)[A].
      • Ciclopirox 1% shampoo twice weekly (1)[A]
    • Topical corticosteroids
      • Begin with 1% hydrocortisone and advance to more potent (fluorinated) steroid preparations, as needed (1,4,5,6)[A].
        • Avoid continuous use of the more potent steroids to reduce the risk of skin atrophy, hypopigmentation, or systemic absorption (especially in infants and children).
        • Precautions: Fluorinated corticosteroids and higher concentrations of hydrocortisone (e.g., 2.5%) may cause atrophy or striae if used on the face or on skin folds.
    • Other topical agents
      • Coal tar 1% shampoo twice a week Selenium sulfide 2.5% shampoo twice a week (1,4,5,6)[A]
      • Zinc pyrithione shampoo twice a week
      • Lithium succinate ointment twice a week
  • Once controlled, washing with zinc soaps or selenium lotion with periodic use of steroid cream may help to maintain remission.
Second Line
  • Calcineurin inhibitors
    • Pimecrolimus 1% cream BID (7)[B]
    • Tacrolimus 0.1% ointment BID (1,4,5,6)[A]
  • Systemic antifungal therapy
    • Data are limited.
    • For moderate to severe seborrheic dermatitis
      • Ketoconazole: 200 mg/day (8)[A]
      • Itraconazole: 200 mg/day (8)[A]
      • Daily regimen for 1 to 2 months followed by twice-weekly dosing for chronic treatment
      • Monitor potential hepatotoxic effects.
  • Low-molecular-weight hyaluronic acid
    • Hyaluronic acid sodium salt gel 0.2% BID (9)[B]
No response to first-line therapy and concerns regarding systemic illness (e.g., HIV)
Patient Monitoring
Every 2 to 12 weeks, as necessary, depending on disease severity and degree of patient sophistication
  • In infants, seborrheic dermatitis usually remits after 6 to 8 months.
  • In adults, seborrheic dermatitis is usually chronic and unpredictable, with exacerbations and remissions. Disease is usually easily controlled with shampoos and topical steroids.
1. Dessinioti C, Katsambas A. Seborrheic dermatitis: etiology, risk factors, and treatment: facts and controversies. Clin Dermatol. 2013:31(4):343-351.
2. Hay RJ. Malassezia, dandruff and seborrhoeic dermatitis: an overview. Br J Dermatol. 2011;165(Suppl 2):2-8.
3. Karincaoglu Y, Tepe B, Kalayci B, et al. Is Demodex folliculorum an aetiological factor in seborrhoeic dermatitis? Clin Exp Dermatol. 2009;34(8): e516-e520.
4. Clark GW, Pope SM, Jaboori KA. Diagnosis and treatment of seborrheic dermatitis. Am Fam Physician. 2015;91(3):185-190.
5. Stefanaki I, Katsambas A. Therapeutic update on seborrheic dermatitis. Skin Therapy Lett. 2010;15(5):1-4.
6. Kastarinen H, Oksanen T, Okokon EO, et al. Topical anti-inflammatory agents for seborrheic dermatitis of the face or scalp. Cochrane Database Syst Rev. 2014;(5):CD009446.
7. Kim GK, Rosso JD. Topical pimecrolimus 1% cream in the treatment of seborrheic dermatitis. J Clin Aesthet Dermatol. 2013;6(2):29-35.
8. Gupta AK, Richarson M, Paquet M. Systematic review of oral treatments for seborrheic dermatitis. J Eur Acad Dermatol Venereol. 2014:28(1):16-26.
9. Schlesinger T, Rowland Powell C. Efficacy and safety of a low molecular weight hyaluronic acid topical gel in the treatment of facial seborrheic dermatitis final report. J Clin Aesthet Dermatol. 2014:7(5):15-18.
Additional Reading
  • Bikowski J. Facial seborrheic dermatitis: a report on current status and therapeutic horizons. J Drugs Dermatol. 2009;8(2):125-133.
  • Darabi K, Hostetler SG, Bechtel MA, et al. The role of Malassezia in atopic dermatitis affecting the head and neck of adults. J Am Acad Dermatol. 2009;60(1):125-136.
  • Johnson BA, Nunley JR. Treatment of seborrheic dermatitis. Am Fam Physician. 2000;61(9):2703-2710, 2713-2714.
  • Naldi L, Rebora A. Clinical practice. Seborrheic dermatitis. N Engl J Med. 2009;360(4):387-396.
  • Shemer A, Kaplan B, Nathansohn N, et al. Treatment of moderate to severe facial seborrheic dermatitis with itraconazole: an open non-comparative study. Isr Med Assoc J. 2008;10(6):417-418.
See Also
Algorithm: Rash, Focal
  • L21.9 Seborrheic dermatitis, unspecified
  • L21.1 Seborrheic infantile dermatitis
  • L21.0 Seborrhea capitis
Clinical Pearls
  • Search for an underlying systemic disease in a patient who is unresponsive to usual therapy.
  • In adults, seborrheic dermatitis is usually chronic and unpredictable, with exacerbations and remissions. Disease is usually easily controlled with shampoos and topical steroids.