dandruff 

Seborrheic dermatitis is a common skin condition that mainly affects the scalp. It causes scaly patches, red skin, and stubborn dandruff. Seborrheic dermatitis doesn’t affect patients overall health, but it can be uncomfortable and cause embarrassment. Moreover, it is not contagious, and it’s not a sign of poor personal hygiene. As asked by some eminent colleagues of mine namely Dr. Nageswara Rao Juvvala, Dr. Amar Deep, Dr. Vidya Chander and Dr. Pradip Das about some information and treatment option of the common dermatological condition of Seborrheic dermatitis, I will try to outline the an overview of the above mentioned condition and its clinical management in this article. Classification and presentation Seborrheic dermatitis generally affects oily areas of the body as follows: Scalp: The mildest and most common form of scalp seborrheic dermatitis is dandruff, also known as pityriasis sicca (Cradle cap in infants), in which the scalp shows fine, white, diffuse scaliness without underlying erythema. Lesions may extend to the post­ auricular areas where they often develop fissures, oozing, and crusting, and to the outer canal and concha of the ear, sometimes with marked pruritus and superinfection (otitis externa). Face: Facial lesions favor the forehead below the hairline, the eyebrows and glabella, and the nasolabial folds. The mustache and beard area are frequently involved in men with facial hair. Periocular: Blepharitis with redness of the free margin of the eyelids and yellow crusting between the eyelashes may be the sole manifestation of seborrheic dermatitis A detailed description of this condition and its management can be found in the article titled “Blepharitis, A Potent Cause For Dry Eye” in Docplexus. Trunk: Major five manifestations are as follows: Moist, erythematous intertrigo of the axillae, infra­mammary folds, umbilicus, and genitocrural area The “petaloid pattern,” consisting of polycyclic, finely scaly, thin plaques over the sternum or interscapular area Annular or arcuate, round to oval, slightly scaly plaques on the trunk, sometimes with hypopigmented central clearing, known as “seborrheic eczematids” The pityriasiform pattern mimicking pityriasis rosea, comprised of scaly lesions distributed along the skin tension lines The psoriasiform pattern with larger red, rounded plaques, with thicker scales Etiology It is largely of unknown etiology. Some clinical evidence relates it to An infection of fungus called Malassezia An inflammatory response related to psoriasis Clinical course Seborrheic dermatitis is a chronic, relapsing condition that may continue throughout one’s lifetime. Factors like stress and cold are known to indicative in aggravating the disease. As sun and Ultraviolet light has precipitating role, Photo-therpaeutic options with psoralen and UVA (PUVA) has been indicated at times. Diagnosis The diagnosis of seborrheic dermatitis is usually made clinically based on the appearance and location of the lesions. Differential diagnosis Psoriasis Rosacea Tinea Versicolor Tinea corporis Secondary syphilis Butterfly eruption of acute SLE Treatment The available treatments for seborrheic dermatitis include topical corticosteroids, topical antifungal agents, and several systemic topical agents with nonspecific antimicrobial, anti-inflammatory, or keratolytic properties. Topical antifungal: Topical antifungal agents are well established in the treatment of seborrheic dermatitis of the scalp, face, and body because of their ability to decrease the population of Malassezia furfur and its related inflammation on the affected skin. Following topical antifungal agents are used in the treatment: Ketoconazole Bifonazole Ciclopirox Olamine Application of antifungal shampoos (eg. ketoconazole 2%, selenium sulfide 2.5%, ciclopirox 1%, fluocinolone acetonide 0.01% etc are examples of antifungal shampoos) in treating seborrheic dermatitis has been proved useful. Topical steroids: Prescription-strength hydrocortisone, fluocinolone, and desonide are corticosteroids that can be applied to the scalp or other affected areas. They’re effective and easy to use. But if used for many weeks or months without a break, they can cause side effects, such as thinning skin or skin showing streaks or lines. Topical calcineurin inhibitors: Pimecrolimus 1% cream. Tacrolimus 0.1% ointment. However, adverse events (mild skin reaction, burning sensation) were reported in pimecrolimus-treated patients. Retinoids: With severe cases of dandruff and seborrheic dermatitis, 13-cis-retinoic acid or retinoic acid can be taken orally and is highly effective. Pregnancy is a contraindication for this medication. Systemic treatments: The use of following oral antifungal agents in systemic therapy is indicated for seborrheic dermatitis Itraconazole Ketoconazole Fluconazole Terbinafine Approach to therapeutic management For patients with seborrheic dermatitis of the scalp who have desquamation, inflammation, and pruritus, a treatment with an antifungal shampoo such as selenium sulfide 2.5%, ketoconazole 2% or ciclopirox 1% with or without a topical high­potency corticosteroid is suggested. The use of the medicated shampoo once a week may be helpful to prevent relapse. Serious adverse effects have not been reported with antifungal shampoos. Irritation and/or burning sensation have been reported in few cases. Some patients complain of dryness of the hair, which can be treated with an over­the­counter conditioner. Inflammation and itching may be controlled with high­potency topical corticosteroid shampoo, lotion, or foam applied once daily for two to four weeks. Several high­potency steroid shampoos like fluocinolone acetonide 0.01% shampoo are also prescribed sometimes. Dandruff (diffuse, fine desquamation without inflammation) is the mildest form of seborrheic dermatitis of the scalp. Limited data from randomized trials suggest that dandruff may be treated with over­the­counter medicated anti-dandruff shampoos containing selenium sulfide 2.5% or zinc pyrithione 1 to 2%, coal tar, or salicylic acid. Rotation of different classes of shampoos (coal tar, selenium sulfide, salicylic acid, and zinc pyrithione­based) seems to improve and maintain efficacy of these formulations and reduce chances of relapse. Seborrheic dermatitis of the face is managed with a low-­potency topical corticosteroid cream (least potential to avoid the adeverse effect of long-term use), a topical antifungal agent, or a combination of the two and topical calcineurin inhibitors. Alternative topical antifungal agents ketoconazole 2% cream or face wash (for men with beard and mustache shampooing with Ketoconazole), other azole creams, and ciclopirox 1% cream are applied on affected area For patients with seborrheic dermatitis of the trunk and intertriginous areas, we suggest treatment with topical corticosteroid creams, topical antifungal agents, or a combination of the two. The topical corticosteroid cream is applied to the affected areas once or twice daily only until symptoms subside. Some alternative therapies with tea tree oil, fish oil supplements, and aloe vera have been reported to give some relief, but they are not well studied and efficacy is not conclusive. A perfect combination of theoretical knowledge and experience of visual inspection may lead to an accurate diagnosis and treatment for this recurring, irritating condition. Source: McGinley KJ, Leyden JJ, Marples RR, Kligman AM. Quantitative microbiology of the scalp in non­dandruff, dandruff, and seborrheic dermatitis. J Invest Dermatol 1975; 64:401. Mayo Clinic UpToDate®

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