Seborrheic Dermatitis (Clinical)

Epidemiology and Etiology

Seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) ( SD SD The standard deviation (SD) is a measure of how far each observed value is from the mean in a data set. Measures of Central Tendency and Dispersion) is a common chronic skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions disorder that is characterized by erythematous patches Patches Vitiligo with greasy, yellowish scales Scales Dry or greasy masses of keratin that represent thickened stratum corneum. Secondary Skin Lesions that most often appear in areas with prominent sebaceous glands (scalp, face, upper trunk, and anogenital area).^[1,2]

Epidemiology^[1,2,6]

• Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency: 3% of the general adult population
• More common in men
• Bimodal distribution Bimodal distribution Measures of Central Tendency and Dispersion (occurs in 2 peaks): 1st in infancy, then in adolescence and early adulthood
  • Up to 70% of infants < 3 months of age are affected, but improvement is noted by 1 year.
  • In adults, the disease peaks between 40 and 60 years.

Etiology and pathophysiology^[1‒3,6,7]

Unclear, but may be affected by the following:

• Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions colonization Colonization Bacteriology of Malassezia Malassezia Malassezia is a lipophilic yeast commonly found on the skin surfaces of many animals, including humans. In the presence of certain environments or triggers, this fungus can cause pathologic diseases ranging from superficial skin conditions (tinea versicolor and dermatitis) to invasive disease (e.g., Malassezia folliculitis, catheter-associated fungemia, meningitis, and urinary tract infections). Malassezia Fungi (lipophilic yeast Yeast A general term for single-celled rounded fungi that reproduce by budding. Brewers’ and bakers’ yeasts are saccharomyces cerevisiae; therapeutic dried yeast is yeast, dried. Mycology) and its interaction with lipids Lipids Lipids are a diverse group of hydrophobic organic molecules, which include fats, oils, sterols, and waxes. Fatty Acids and Lipids on skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions surface:
  • Association is strongly suggested because antifungal Antifungal Azoles agents decrease Malassezia Malassezia Malassezia is a lipophilic yeast commonly found on the skin surfaces of many animals, including humans. In the presence of certain environments or triggers, this fungus can cause pathologic diseases ranging from superficial skin conditions (tinea versicolor and dermatitis) to invasive disease (e.g., Malassezia folliculitis, catheter-associated fungemia, meningitis, and urinary tract infections). Malassezia Fungi organisms and effectively treat the disease.
  • Yeast Yeast A general term for single-celled rounded fungi that reproduce by budding. Brewers’ and bakers’ yeasts are saccharomyces cerevisiae; therapeutic dried yeast is yeast, dried. Mycology produces lipases Lipases An enzyme of the hydrolase class that catalyzes the reaction of triacylglycerol and water to yield diacylglycerol and a fatty acid anion. It is produced by glands on the tongue and by the pancreas and initiates the digestion of dietary fats. Lipid Metabolism and phosphatases Phosphatases Oxazolidinones, which cleave fatty acids Acids Chemical compounds which yield hydrogen ions or protons when dissolved in water, whose hydrogen can be replaced by metals or basic radicals, or which react with bases to form salts and water (neutralization). An extension of the term includes substances dissolved in media other than water. Acid-Base Balance from sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis → release inflammatory free fatty acids Acids Chemical compounds which yield hydrogen ions or protons when dissolved in water, whose hydrogen can be replaced by metals or basic radicals, or which react with bases to form salts and water (neutralization). An extension of the term includes substances dissolved in media other than water. Acid-Base Balance → aberrant keratinocyte Keratinocyte Epidermal cells which synthesize keratin and undergo characteristic changes as they move upward from the basal layers of the epidermis to the cornified (horny) layer of the skin. Successive stages of differentiation of the keratinocytes forming the epidermal layers are basal cell, spinous or prickle cell, and the granular cell. Erythema Multiforme production →  abnormal stratum corneum Stratum corneum Skin: Structure and Functions  → inflammatory response stimulated → skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions eruption
• Individual susceptibility:
  • Increased sebaceous gland Sebaceous Gland Small, sacculated organs found within the dermis. Each gland has a single duct that emerges from a cluster of oval alveoli. Each alveolus consists of a transparent basement membrane enclosing epithelial cells. The ducts from most sebaceous glands open into a hair follicle, but some open on the general surface of the skin. Sebaceous glands secrete sebum. Hordeolum (Stye) activity (seborrhea → seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) found in areas with abundant sebaceous glands)
  • Stress
• Immune dysregulation/ immunodeficiency Immunodeficiency Chédiak-Higashi Syndrome:
  • HIV HIV Anti-HIV Drugs infection:
    • Seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) affects up to 85% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with AIDS AIDS Chronic HIV infection and depletion of CD4 cells eventually results in acquired immunodeficiency syndrome (AIDS), which can be diagnosed by the presence of certain opportunistic diseases called AIDS-defining conditions. These conditions include a wide spectrum of bacterial, viral, fungal, and parasitic infections as well as several malignancies and generalized conditions. HIV Infection and AIDS.
    • Severe seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with low CD4 counts
  • Lymphoma Lymphoma A general term for various neoplastic diseases of the lymphoid tissue. Imaging of the Mediastinum
  • Renal transplantation
• Neuropsychiatric conditions:
  • Parkinson disease: 
    • Increased sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis production
    • Improvement of seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) with use of levodopa Levodopa The naturally occurring form of dihydroxyphenylalanine and the immediate precursor of dopamine. Unlike dopamine itself, it can be taken orally and crosses the blood-brain barrier. It is rapidly taken up by dopaminergic neurons and converted to dopamine. It is used for the treatment of parkinsonian disorders and is usually given with agents that inhibit its conversion to dopamine outside of the central nervous system. Parkinson’s Disease Drugs
  • Alzheimer dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders, depression
• Alcoholism Alcoholism A primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic. Wernicke Encephalopathy and Korsakoff Syndrome
• Climate changes (worse in cold temperatures, some improve with sun exposure)
• Medications: lithium Lithium An element in the alkali metals family. It has the atomic symbol li, atomic number 3, and atomic weight [6. 938; 6. 997]. Salts of lithium are used in treating bipolar disorder. Ebstein’s Anomaly, haloperidol Haloperidol A phenyl-piperidinyl-butyrophenone that is used primarily to treat schizophrenia and other psychoses. It is also used in schizoaffective disorder, delusional disorders, ballism, and tourette syndrome (a drug of choice) and occasionally as adjunctive therapy in intellectual disability and the chorea of huntington disease. It is a potent antiemetic and is used in the treatment of intractable hiccups. First-Generation Antipsychotics, chlorpromazine Chlorpromazine The prototypical phenothiazine antipsychotic drug. Like the other drugs in this class chlorpromazine’s antipsychotic actions are thought to be due to long-term adaptation by the brain to blocking dopamine receptors. Chlorpromazine has several other actions and therapeutic uses, including as an antiemetic and in the treatment of intractable hiccup. First-Generation Antipsychotics, immunosuppressants Immunosuppressants Immunosuppressants are a class of drugs widely used in the management of autoimmune conditions and organ transplant rejection. The general effect is dampening of the immune response. Immunosuppressants, psoralen Psoralen Melanoma, dopamine Dopamine One of the catecholamine neurotransmitters in the brain. It is derived from tyrosine and is the precursor to norepinephrine and epinephrine. Dopamine is a major transmitter in the extrapyramidal system of the brain, and important in regulating movement. Receptors and Neurotransmitters of the CNS antagonists

Clinical Presentation

General features^[2,4,6]

• Pruritic, erythematous papules and plaques
• Easily detachable greasy scales Scales Dry or greasy masses of keratin that represent thickened stratum corneum. Secondary Skin Lesions and yellow crusts
• Remits and relapses

Seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) in infants^[2,4,6,8]

• Typically appears in the 2nd week of life and lasts for 4‒6 months
• Affected areas:
  • Head:
    • Scalp (“cradle cap”)
    • Eyebrows, eyelids Eyelids Each of the upper and lower folds of skin which cover the eye when closed. Blepharitis, nasolabial and retroauricular folds, and neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess
  • Trunk: umbilicus and intertriginous areas Intertriginous areas Malassezia Fungi (opposite of atopic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema), which spares the intertriginous areas Intertriginous areas Malassezia Fungi)
• Leiner disease Leiner Disease Seborrheic Dermatitis:
  • Rare disease associated with complement (C5) deficiency
  • Generalized severe seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema)
  • Also with diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea and/or vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia, anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and Types, or failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive

Seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) in adults^[2,4,6,7]

Affected areas:

• Scalp: dandruff Dandruff Excessive shedding of dry scaly material from the scalp in humans. Seborrheic Dermatitis/ pityriasis sicca Pityriasis sicca Excessive shedding of dry scaly material from the scalp in humans. Seborrheic Dermatitis; fine, white, flaking scales Scales Dry or greasy masses of keratin that represent thickened stratum corneum. Secondary Skin Lesions on the scalp
• Face:
  • Eyebrows, glabella, eyelids Eyelids Each of the upper and lower folds of skin which cover the eye when closed. Blepharitis
  • Sides of the nose Nose The nose is the human body’s primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Nose Anatomy (External & Internal), nasolabial folds (opposite of lupus, which spares the nasolabial folds)
  • Mustache and beard areas; improves with shaving
• Trunk:
  • Intertriginous areas Intertriginous areas Malassezia Fungi ( axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus: Anatomy, inframammary folds, anogenital region) 
  • Upper chest and back
  • Pityriasiform type: may distribute along skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions tension lines in 5‒15-mm oval lesions

Seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with HIV HIV Anti-HIV Drugs^[2,4,6]

• In patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with CD4 counts < 400 cells/µL, lesions may be widespread and difficult to control.
• Seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) can be the initial clinical cutaneous marker for HIV HIV Anti-HIV Drugs/ AIDS AIDS Chronic HIV infection and depletion of CD4 cells eventually results in acquired immunodeficiency syndrome (AIDS), which can be diagnosed by the presence of certain opportunistic diseases called AIDS-defining conditions. These conditions include a wide spectrum of bacterial, viral, fungal, and parasitic infections as well as several malignancies and generalized conditions. HIV Infection and AIDS:
  • Sudden severe onset
  • Atypical distribution of lesions 
  • Treatment resistance Resistance Physiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow. Ventilation: Mechanics of Breathing
• May improve with antiretroviral therapy Antiretroviral therapy Antiretroviral therapy (ART) targets the replication cycle of the human immunodeficiency virus (HIV) and is classified based on the viral enzyme or mechanism that is inhibited. The goal of therapy is to suppress viral replication to reach the outcome of undetected viral load. Anti-HIV Drugs

Diagnosis

The diagnosis is typically based on clinical findings. Additional studies may be performed if the diagnosis is uncertain or to rule out other conditions.^[1‒3,8]

• Biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma can be used if the diagnosis is uncertain. Findings on biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma:
  • Superficial perivascular inflammatory infiltrates ( neutrophils Neutrophils Granular leukocytes having a nucleus with three to five lobes connected by slender threads of chromatin, and cytoplasm containing fine inconspicuous granules and stainable by neutral dyes. Innate Immunity: Phagocytes and Antigen Presentation, lymphocytes Lymphocytes Lymphocytes are heterogeneous WBCs involved in immune response. Lymphocytes develop from the bone marrow, starting from hematopoietic stem cells (HSCs) and progressing to common lymphoid progenitors (CLPs). B and T lymphocytes and natural killer (NK) cells arise from the lineage. Lymphocytes: Histology)
  • Psoriasiform hyperplasia Psoriasiform Hyperplasia Seborrheic Dermatitis
  • Parakeratosis Parakeratosis Persistence of the nuclei of the keratinocytes into the stratum corneum of the skin. This is a normal state only in the epithelium of true mucous membranes in the mouth and vagina. Actinic Keratosis (retention of nuclei in the stratum corneum Stratum corneum Skin: Structure and Functions)
  • Focal spongiosis Focal Spongiosis Seborrheic Dermatitis (the presence of any spongiosis favors seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) over psoriasis Psoriasis Psoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis)
  • Yeast Yeast A general term for single-celled rounded fungi that reproduce by budding. Brewers’ and bakers’ yeasts are saccharomyces cerevisiae; therapeutic dried yeast is yeast, dried. Mycology species in the stratum corneum Stratum corneum Skin: Structure and Functions
• Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions scraping with potassium Potassium An element in the alkali group of metals with an atomic symbol k, atomic number 19, and atomic weight 39. 10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte that plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. Hyperkalemia hydroxide (KOH) preparation → can visualize fungal infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease 
• In HIV HIV Anti-HIV Drugs: more parakeratosis Parakeratosis Persistence of the nuclei of the keratinocytes into the stratum corneum of the skin. This is a normal state only in the epithelium of true mucous membranes in the mouth and vagina. Actinic Keratosis, increased inflammatory infiltrate, and less spongiosis

Differential diagnosis^[2,3,6]

Seborrheic dermatitis Dermatitis Any inflammation of the skin. Atopic Dermatitis (Eczema) must be differentiated from other dermatologic conditions, which is typically done based on history and exam features alone.

Management

Management may vary depending on practice location. The following information is primarily based on US literature. Additional information from the National Institute for Health and Care Excellence is available for members for the UK.

General approach^{[1‒3,7,8,10]}

The goal of treatment is to reduce erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion and pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema).

• Avoid cold temperatures.
• Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions protection:
  • Wash with gentle soaps (e.g., avoid those containing fragrance).
  • Avoid personal care products with harsh chemicals or alcohol.
  • Wear loose-fitting clothing.
  • Wear sunscreen Sunscreen Chemical or physical agents that protect the skin from sunburn and erythema by absorbing or blocking ultraviolet radiation. Melanoma (opt for ones containing zinc Zinc A metallic element of atomic number 30 and atomic weight 65. 38. It is a necessary trace element in the diet, forming an essential part of many enzymes, and playing an important role in protein synthesis and in cell division. Zinc deficiency is associated with anemia, short stature, hypogonadism, impaired wound healing, and geophagia. It is known by the symbol zn. Trace Elements oxide or titanium dioxide).
• Discontinue medications that can trigger Trigger The type of signal that initiates the inspiratory phase by the ventilator Invasive Mechanical Ventilation flares.
• Treat associated comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus.

Medical therapy^[1‒3,7,8]

Treatment options include topical antifungal Antifungal Azoles agents, topical antiinflammatory agents ( steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors and calcineurin inhibitors Calcineurin Inhibitors Compounds that inhibit or block the phosphatase activity of calcineurin. Immunosuppressants), and several miscellaneous agents. Combination therapy can be used for more severe cases.

Since SD SD The standard deviation (SD) is a measure of how far each observed value is from the mean in a data set. Measures of Central Tendency and Dispersion is a chronic condition, rotating treatment options helps to reduce adverse reactions associated with persistent monotherapy.

Topical antifungals (and other agents with antifungal Antifungal Azoles properties):

1st-Line therapy on the face and body (a mainstay of therapy to help reduce Malassezia Malassezia Malassezia is a lipophilic yeast commonly found on the skin surfaces of many animals, including humans. In the presence of certain environments or triggers, this fungus can cause pathologic diseases ranging from superficial skin conditions (tinea versicolor and dermatitis) to invasive disease (e.g., Malassezia folliculitis, catheter-associated fungemia, meningitis, and urinary tract infections). Malassezia Fungi):

• Ketoconazole Ketoconazole Broad spectrum antifungal agent used for long periods at high doses, especially in immunosuppressed patients. Azoles 2%:
  • Shampoo:
    • Apply twice per week to the scalp or skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions for 2‒4 weeks, then once weekly for maintenance.
    • When applying to the scalp, use 5‒10 mL and leave on for 3‒5 minutes prior to rinsing.
  • Cream or foam: Apply to the affected area twice daily for 4 weeks.
  • Gel: Apply to the affected area once daily for 2 weeks.
• Miconazole Miconazole An imidazole antifungal agent that is used topically and by intravenous infusion. Azoles 2% cream or ointment: Apply to affected area 1‒2 times daily.
• Sertaconazole 2% cream: Apply twice daily for up to 4 weeks.
• Ciclopirox olamine 1.5% shampoo, cream, gel, or lotion:
  • Scalp: Apply 2‒3 times per week for 4 weeks, then once weekly for maintenance.
  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions: Apply to affected areas twice daily.
• Selenium sulfide Selenium Sulfide Seborrheic Dermatitis 2.5% shampoo:
  • Has antifungal Antifungal Azoles and keratolytic properties
  • Dosing: Apply twice per week to the scalp for 2 weeks, then once weekly for 2 weeks, then repeat after 4‒6 weeks.
• Zinc pyrithione Zinc Pyrithione Seborrheic Dermatitis 1% or 2% shampoo:
  • Has fungistatic Fungistatic Azoles and antibacterial Antibacterial Penicillins properties
  • Dosing: Apply to the scalp 2‒3 times per week.

Topical antiinflammatory agents:

2nd-Line agents are best used to treat acute flares, but they are not recommended for continuous long-term use owing to the risks of potential adverse effects.

• Topical corticosteroids Corticosteroids Chorioretinitis:
  • May be used either alone or in combination with topical antifungal Antifungal Azoles agents for SD SD The standard deviation (SD) is a measure of how far each observed value is from the mean in a data set. Measures of Central Tendency and Dispersion on the scalp, face, or trunk
  • Long-term use is not recommended owing to the risk of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation, hypopigmentation Hypopigmentation A condition caused by a deficiency or a loss of melanin pigmentation in the epidermis, also known as hypomelanosis. Hypopigmentation can be localized or generalized, and may result from genetic defects, trauma, inflammation, or infections. Malassezia Fungi, and irritation.
  • Options:
    • Hydrocortisone Hydrocortisone The main glucocorticoid secreted by the adrenal cortex. Its synthetic counterpart is used, either as an injection or topically, in the treatment of inflammation, allergy, collagen diseases, asthma, adrenocortical deficiency, shock, and some neoplastic conditions. Immunosuppressants 1% cream or ointment: Apply to the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions 1‒2 times daily.
    • Betamethasone Betamethasone A glucocorticoid given orally, parenterally, by local injection, by inhalation, or applied topically in the management of various disorders in which corticosteroids are indicated. Its lack of mineralocorticoid properties makes betamethasone particularly suitable for treating cerebral edema and congenital adrenal hyperplasia. Glucocorticoids valerate 0.12% foam/0.1% cream: Apply twice daily.
    • Betamethasone Betamethasone A glucocorticoid given orally, parenterally, by local injection, by inhalation, or applied topically in the management of various disorders in which corticosteroids are indicated. Its lack of mineralocorticoid properties makes betamethasone particularly suitable for treating cerebral edema and congenital adrenal hyperplasia. Glucocorticoids dipropionate 0.05% lotion: Apply 1‒2 times daily.
    • Clobetasol Clobetasol A derivative of prednisolone with high glucocorticoid activity and low mineralocorticoid activity. Absorbed through the skin faster than fluocinonide, it is used topically in treatment of psoriasis but may cause marked adrenocortical suppression. Glucocorticoids 0.05% shampoo: Apply twice weekly for 2 weeks (then use ketoconazole Ketoconazole Broad spectrum antifungal agent used for long periods at high doses, especially in immunosuppressed patients. Azoles shampoo for 2 weeks).
    • Fluocinolone 0.01% shampoo, lotion, or cream: Apply to the scalp or skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions once or twice daily.
    • Desonide 0.05% cream, lotion, ointment, gel, or foam: Apply to the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions once or twice daily.
• Calcineurin inhibitors Calcineurin Inhibitors Compounds that inhibit or block the phosphatase activity of calcineurin. Immunosuppressants:
  • Suppress cytokine production
  • Have fewer side effects than corticosteroids Corticosteroids Chorioretinitis
  • Avoid continuous long-term use owing to possible association with lymphoma Lymphoma A general term for various neoplastic diseases of the lymphoid tissue. Imaging of the Mediastinum and skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions cancer.
  • Limit Limit A value (e.g., pressure or time) that should not be exceeded and which is specified by the operator to protect the lung Invasive Mechanical Ventilation use to the affected areas.
  • Options:
    • Tacrolimus Tacrolimus A macrolide isolated from the culture broth of a strain of streptomyces tsukubaensis that has strong immunosuppressive activity in vivo and prevents the activation of T-lymphocytes in response to antigenic or mitogenic stimulation in vitro. Immunosuppressants 0.1% ointment: Apply to the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions 1‒2 times daily for 4 weeks, then twice per week for maintenance.
    • Pimecrolimus Pimecrolimus Immunosuppressants 1% cream: Apply to the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions 1‒2 times daily.

Miscellaneous topical agents:

• Coal tar Coal Tar A by-product of the destructive distillation of coal used as a topical antieczematic. It is an antipruritic and keratoplastic agent used also in the treatment of psoriasis and other skin conditions. Occupational exposure to soots, tars, and certain mineral oils is known to be carcinogenic according to the fourth annual report on carcinogens. Psoriasis 4% shampoo (sometimes with salicylic acid): Apply to the scalp 1‒2 times per week.
  • Antiinflammatory
  • Antifungal Antifungal Azoles 
  • Keratolytic
  • Reduces sebum Sebum The oily substance secreted by sebaceous glands. It is composed of keratin, fat, and cellular debris. Infectious Folliculitis production
• Metronidazole Metronidazole A nitroimidazole used to treat amebiasis; vaginitis; trichomonas infections; giardiasis; anaerobic bacteria; and treponemal infections. Pyogenic Liver Abscess 0.75% gel (antiinflammatory): Apply to the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions twice daily for 4‒8 weeks.
• Lithium Lithium An element in the alkali metals family. It has the atomic symbol li, atomic number 3, and atomic weight [6. 938; 6. 997]. Salts of lithium are used in treating bipolar disorder. Ebstein’s Anomaly gluconate/succinate 8% gel or ointment (antiinflammatory):
  • Available in Europe but not in the US
  • Dosing: Apply to the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions twice daily for 8 weeks.
• Tea tree oil (Melaleuca alternifolia) 5% shampoo:
  • Some evidence suggests benefit for treating scalp SD SD The standard deviation (SD) is a measure of how far each observed value is from the mean in a data set. Measures of Central Tendency and Dispersion.
  • Has documented estrogenic and anti-androgenic properties; however, generally considered safe
  • Can be applied daily

Oral antifungal Antifungal Azoles agents:

• Indications:
  • SD SD The standard deviation (SD) is a measure of how far each observed value is from the mean in a data set. Measures of Central Tendency and Dispersion involving multiple body areas
  • Failed topical therapies
• Options:
  • Ketoconazole Ketoconazole Broad spectrum antifungal agent used for long periods at high doses, especially in immunosuppressed patients. Azoles 200 mg once daily for 4 weeks 
  • Itraconazole Itraconazole A triazole antifungal agent that inhibits cytochrome p-450-dependent enzymes required for ergosterol synthesis. Azoles (has affinity for highly keratinized skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions) 200 mg once daily for 7 days, then once daily for 2 consecutive days per month for maintenance
  • Terbinafine Terbinafine In addition to the 3 other major classes of antifungal agents (azoles, polyenes, and echinocandins), several other clinically important antifungal agents are used, including flucytosine, griseofulvin, and terbinafine. Terbinafine acts within the stratum corneum of the skin and are used to treat dermatophyte infections of the skin, hair, and nails. Flucytosine, Griseofulvin, and Terbinafine 250 mg once daily for 4‒6 weeks (or 12 days per month for 3 months)