Seborrheic dermatoses strategies

"Seborrheic dermatitis is one of the most common conditions seen in dermatology," says Lynda Kauls, M.D., an assistant professor of dermatology at Oregon Health and Science University in Portland, Ore.

"What is interesting is that we still don't know that much about the pathogenesis of the condition, except that it involves a combination of Malassezia species, oil production and an individual's inflammatory reaction. We don't know why some people react to the Malassezia yeast on the skin," Dr. Kauls tells Dermatology Times.

Low-potency topical steroids have traditionally been used to reduce inflammation with minimal problems, Dr. Kauls says.

"With growing experience, we have found that newer agents that treat atopic dermatitis, such as calcineurin inhibitors, can also be helpful in treating seborrheic dermatitis of the face," Dr. Kauls explains.

Tactical treatment options

She notes that in addition to topical antifungals, topical steroids are often a mainstay of treatment of facial seborrheic dermatitis and are effective.

But with a chronic condition, there are concerns such as thinning of the skin and the potential to exacerbate acne or rosacea with repeated use of topical steroids. Consequently, clinicians are looking to alternative therapies that will not produce long-term adverse effects.

One study, published in the Journal of the American Academy of Dermatology in December 2006, compared a vehicle treatment to twice-daily administration of pimecrolimus 1 percent for the treatment of moderate to severe facial seborrheic dermatitis for four weeks. The study measured the differences in erythema and scaling from baseline and found pimecrolimus to be superior to vehicle.

While Dr. Kauls describes calcineurin inhibitors as equivalent to topical steroids in their efficacy as a seborrheic dermatitis treatment, they can be attractive as a therapeutic choice in individuals experiencing adverse effects from topical steroids.

"The thought is that you can avoid some of the steroid side effects, such as atrophy, by using the calcineurin inhibitors," Dr. Kauls says. "It remains to be seen if acne and rosacea can be avoided, as there are reports of acneiform flares with calcineurin inhibitors."

Bring out the big guns

For very refractory cases of seborrheic dermatitis, oral pulses of antifungal agents administered once a month can be implemented, Dr. Kauls explains.

"By the time we see patients who have it on the scalp, they have usually tried over-the-counter shampoos, which aren't working," Dr. Kauls says.

"We use medicated shampoos, either containing corticosteroids or antifungal properties. We can also use steroid solutions or foams in the scalp. Selenium sulfide 2.5 percent shampoo is a low-cost and useful shampoo with antifungal properties, and I often recommend that patients use it in the shower if they have additional areas of involvement besides the scalp, such as the face and chest, to prevent flares."

Many of the new treatments on the market are not distinctive in their key ingredients, but represent a new formulation or vehicle of an available agent.

"Treating seborrheic dermatitis is about finding the right vehicle for the patient," Dr. Kauls says. "In many instances, the new medications that are on the market represent a change in vehicle for patients. An example is the antifungal agent ketoconazole, available as a gel instead of a cream."

Customizing treatment

The appropriate therapy choice is dependent on the presentation of the condition: If the condition presents as highly inflamed and itchy, an anti-inflammatory agent is in order, while an antifungal is a prudent choice for long-term safety and control.