Seborrheic Dermatitis: When Conventional Treatments Fail

Systematic review of oral treatments for seborrheic dermatitis.
Gupta AK, Richardson M, Paquet M.
J Eur Acad Dermatol Venereol. 2014 Jan;28(1):16-26. doi: 10.1111/jdv.12197. Epub 2013 Jun 26.

• Seborrheic dermatitis (SD)  is a common inflammatory disorder which affects:

1. the scalp where it creates flaking of the skin or what is known as common dandruff (Pityriasis capitis).
2. the face where it creates erythema (redness) and scaling usually localized to the nasogenial folds and the eyebrows.

• Its cause is unknown but it is strongly linked with regards to its severity to the presence of a yeast of the Malassezia species. Because of this, its main treatment consists of applying a topical antifungal cream twice a day.
• Other treatments consist of applying OTC (over-the-counter) creams with anti-redness properties (mostly for their moisturizing anti-irritating properties).
• However, these measures are sometimes not enough and an oral treatment can be proposed (although no cure has been found to this date). The following review article summarizes them:

• antifungals: some evidence, but the problem is that monitoring of yeast count/density was not performed in half of the studies. Also many stuies were not randomized-control trials (RCT).
  • Itraconzole: 200mg daily for the first week of the month then 200mg for the first two days of the month for up to a year.
  • Terbinafine: 250mg daily  for 4 to 6 weeks then 250mg 12 days per month for 3 months. Comment: terbinafine is not usually effective against yeasts and there is probably an alternative mechanism to its mode of action.
  • Fluconazole: 50mg daily for 2 weeks or 200-300mg weekly for up to 4 weeks. In our clinical experience we have seen some effect and the studies performed included mild to moderate SD (wheareas the other studies only included moderate-to-severe SD, or unresponsive to conventional treatments)
  • Ketoconazole: 200mg daily for 4 weeks.
  • Pramiconazole: 200mg as a single dose.

• oral prednisone: one case report. 0.5mg/Kg for 15 days with progressive tapering.
• oral isotretinoin: one case report. 20mg daily in combination with topical ketoconazole.
• homeopathic preparation of potassium bromide, sodium bromide, nickel sulfate and sodium chloride, one RCT with 53 patients showing a maximum effect after 15 weeks (www.almedrev.com/publications/7/1/59.pdf)

Contributors

Dr Christophe Hsu – dermatologist. Geneva, Switzerland