seborrheic dermatitis - semantic scholar · resistant cases of seborrheic dermatitis. diagnosis of...

American Family Physician

Seborrheic DermatitisCAMILA K. JANNIGER, M.D., and ROBERT A. SCHWARTZ, M.D., M.P.H.UMDNJ-New Jersey Medicai School, Newark, New Jersey

SeborrheJc dermatitis is a common condi-tion that usually appears as simple dan-druff, it may affect the scaip, the centrai partof the face and the anterior portion of thechest, as weit as fiexurai creases of thearms, legs and groin, it occurs most often ininfants and in adults between 30 and 60years of age. Patients with acquired immuno-deficiency syndrome may have particuiarlyresistant cases of seborrheic dermatitis.Diagnosis of this condition is generaiiystraightforward, but the differential diagno-sis includes a variety of conditions, such aspsoriasis vulgaris (sebopsoriasis), atopicdermatitis, tinea capltis and candidiasis, asweii as other, more rare conditions. Sebor-rheic dermatitis may be associated with orcaused by a variety of underiying disorders.Treatment is generaiiy topical. Steroidcreams, seienium, saiicylic acid and coal tarpreparations, and pyrithione zinc are fre-quentiy used to treat this condition.

Seborrheic dermatitis is one of the mostcommon disorders, affecting persons of allages.'"*' It occurs more frequently in infantswithin the first three months of life and inadults 30 to 60 years of age. In the lattergroup, it tends to affect men more oftenthan women. In adolescents and adults,seborrheic dermatitis commonly is mani-fested as "dandruff" or as an erythema ofthe nasolabial fold, ranging in intensityfrom barely perceptible to marked. Interesthas increased in seborrheic dermatitis inits generalized form in infants with im-mune deficits^"'" and in a more recent asso-ciation with acquired immunodeficiencysyndrome."'"'

Clinical Description

In adolescents and adults, seborrheicdermatitis typically presents as mild.

FIGURE 1. Seborrheic dermatitis of the scalp.

greasy scaling of the scalp (Figure 1), witherythema and scaling of the nasolabialfolds and retroauricular skin. Seborrheicdermatitis appears in areas of increasedsebaceous gland activity, often in associa-tion with an oily complexion. It may in-volve the auricles, beard area, eyebrows,flexures and trunk. Associated blepharitismay be present, sometimes with meibomi-an gland occlusion and abscess formation.Otihs extema may also occur.

Two forms of seborrheic dermatitis maybe seen on the chest: a common "peta-loid" type and a rare "pityriasiform"type.^ The first form begins as small,reddish-brown follicular and perifollicu-lar papules with a greasy scale. The pap-ules may enlarge to form patches resem-bling the shape of petals on a flower orsimilar to a medallion in shape ("medal-lion" seborrheic dermatitis). The pityri-asiform type presents as generalizedmacules and patches resembling exten-sive pityriasis rosea but rarely producesan erythroderma.

In infants, a greasy, thick scaling of the

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Seborrheic Dermatitis

vertex of the scalp is common. It is popu-larly known by the descriptive term "cra-dle cap"'-^ {Figure 2). Cradle cap presentsas a dry patch of scaling, overlying, mild-ly erythematous skin that has become sothickened it forms a cap.

Patients with seborrheic dermatitis typi-cally show no evidence of acute dermatitis,such as oozing or weeping. Instead, diffusefine scaling may be white, off-white or yel-lowish in color. (Drier, larger scales aresometimes termed "psoriasiform" sebor-rheic dermatitis." )̂ Scaling is often the onlymanifestation of seborrheic dermatitis ininfants, and usually appears in the third orfourth week after birth. The central part ofthe face, forehead and ears may also beinvolved. On occasion, the process be-comes generalized in otherwise normal,healthy infants. A widespread erythema,often witli a cheesy exudate, may also beevident, principally in the flexural folds.Flexiiral involvement is manifested as dia-per dermatitis in infants and as intertrigi-nous and genital eruption in adults. It mayalso become generalized.

The generalized form of seborrheic der-matitis usually occurs in healthy, normalchildren; rarely, it may be associated with avariety of immune deficiencies in children,and these children usually also have diar-rhea and failure to thrive.̂ ** Some physi-cians consider generalized infantile seb-orrheic dermatitis in children who haveimmune deficiencies to be the same condi-tion as one that occurred in an epidemicinfantile eruption reported under the name"erythroderma desquamativum" in 1908(Leiner's disease).

Infants with generalized seborrheic der-matitis, diarrhea and failure to thriveshould be evaluated for possible immunedeficits, particularly a functional defect inthe fifth component of complement.*^ Thisfamilial disorder is associated with recur-rent infections caused by gram-negativeorganisms. However, other defects havealso been described.^'" In both childrenand adults, persistent generalized sebor-rheic dermatitis may be associated with

FIGURE 2. Two infants with seborrheic dermati-tis on the scalp (cradle cap).

human immunodeficiency virus (HIV)infection."'^ Severe seborrheic dermatitisis quite common in infants who developHIV-related immune suppression in thefirst year of life.'"*

An unusually recalcitrant eruption re-sembling seborrheic dermatitis has beenreported in a high percentage of patientswith AIDS,"-'̂ with an incidence of up to 83percent reported in one study'^ {Figure 3).

FIGURE 3. Severe, persistent seborrheic dermati-tis in a patient with acquired immunodeficiencysyndrome.

150 volume 52, number 1


Seborrheic dermatitis in AIDS patients usu-ally shows a predominance of inflarrunato-ry and hyperkeratotic lesions, with involve-ment of the trunk, groin and extremities. Itoccasionally progresses to erythroderma, acradle cap of scales sometimes associatedwith nonscarring alopecia, and postinflam-matory skin changes of either hyperpig-mentation or hypopigmentation.

DiagnosisThe diagnosis of seborrheic dermatitis is

often obvious. However, if the patient failsto respond to therapy, the diagnosisshould be reconsidered, unless the patienthas AIDS. At times the diagnosis is com-plicated by the coexistence of other disor-ders, especially in patients with AIDS,who may also have psoriasis or deep fun-gal infections such as histoplasmosis.'-'*

DIFFERENTIAL DIAGNOSIS

Psoriasis vulgaris of the scalp, which iscommon in adults, may be difficult to dis-tinguish from seborrheic dermatitis. Theterm "sebopsoriasis" is sometimes used todescribe sharply demarcated scalp plaquesthat are difficult to distinguish from pureseborrheic dermatitis or psoriasis. Otherevidence of psoriasis, such as psoriasiformlesions elsewhere on the body or pitting ofthe nails, may also facilitate this distinction.

Seborrheic dermatitis must also be dis-tinguished from atopic dermatitis, tineacapitis and, rarely, histiocytosis X. Atopicdermatitis in adults tends to affect theantecubital and popliteal fossae. Tinea canbe diagnosed by the presence of hyphaeon cytologic examination with potassiumhydroxide, and candidiasis can be demon-strated by pseudohyphae.'*' In tinea versi-color, shorter hyphae are seen, togetherwith spores (the so-called "spaghetti andmeatball" pattern).^^

Seborrheic dermatitis of the groin mayresemble dermatophytosis, psoriasis andcandidiasis. Seborrheic dermatitis tends tobe bilaterally symmetric, with reddish-brown, fine scaling patches that respondpromptly to therapy.

At times, rosacea may also require dis-tinction.̂ ^ Patients with rosacea usually dis-play central facial erythema, but at timesthey may show involvement of the fore-head only. Another condition that might bemistaken for seborrheic dermatitis of theface is systemic lupus erythematosus.

In infants, atopic dermatitis has thesame sites of predilection as seborrheicdermatitis: the scalp, face, diaper areas andextensor limb surfaces. Axillary involve-ment favors the diagnosis of seborrheicdermatitis, as do lack of scratching andabsence of oozing and weeping. The dis-tinction is made on clinical grounds, sincean elevated IgE level is a nonspecific find-ing in patients with atopic dermatitis.^ Ininfants, a form of atopic dermatitis andseborrheic dermatitis with cradle cap maybe combined. Infants with this conditionmay exhibit an increased incidence ofatopy that falls between that of normalcontrol subjects and that of typical atopicpatients.̂ -^

Similarly, infants with psoriasiform in-fantile seborrheic dermatitis have the sameincidence of psoriasis vulgaris as thosewith classic infantile seborrheic derma-titis.^ However, infants with psoriasiforminfantile seborrheic dermatitis have amuch lower incidence of atopic dermatitis.

Finally, a rare condition to consider inthe differential diagnosis of seborrhea ininfants is histiocytosis X. Affected irxfantshave a scaling, seborrheic, dermatitis-likeeruption on the scalp that occurs In associ-ation with fever and other systemic signsof Letterer-Siwe disease (acute disseminat-ed histiocytosis X).''*The differential diag-nosis of seborrheic dermatitis is summa-rized in Table 1.

Possible Underlying DisordersDeficiencies of riboflavin, biotin or pyri-

doxine are said to be associated with sebor-rheic dermatitis-like eruptions.^"'^^ Asnoted, seborrheic dermatitis may also be asign of AIDS. Seborrheic dermatitis mayhave an increased association with a varietyof neurologic disorders, including parkin-

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TABLE 1

Differential Diagnosisof Seborrheic Dermatitis

Atopic dermatitisCandidiasisIDermatophytosistiistioq'tosis XPsoriasis vulgarisRosacea

Systemic lupuserythema tos us

Tinea capitisTmea versicolorVitamin deficiency

sonism, postcerebrovascular accidents,epilepsy, central nervous system trauma,facial nerve palsy and syringomyelia."

Etiology

The etiology of seborrheic dermatitisremains an enigma. It may be hormonallydependent, which would explain why itappears in infancy and often disappearsspontaneously before puberty. It may noteven be the same disorder in infants as it isin adults. The seborrheic dermatitis ofAIDS may also be a different disease thanadult and infantile seborrheic dermatitis." '̂Seborrheic dermatitis of AIDS probablyrepresents proliferation of the resident fun-gus Pityrosporum ovale, caused by a widevariety of factors.^^ Culture results from

The AuthorsCAMILA K, JANNIGER, M.D.is clinical asstKiate professor, chief of pediatric derma-tology and chief of geriatric dermatology at theUMDNJ-New Jersey Medical School in Newark, Agraduate of the Medical Academy of Warsaw, Dr. Jan-niger completed an internship at the Albert EinsteinCollege of Medicine-Montefiore Hospital, followed bya three-year dermatology residency at the New JerseyMedical School Dr, Janniger has a private practice inWallington,N.J,

ROBERT A. SCHWARTZ, M.D., M,P.H,is professor and head of dermatology, professor of med-icine and professor of pediatrics at UMDNJ-New JerseyMedical School, He is a member of AFP's editorial ad-visory board.

Address correspondence to Camila K. lanniger, M.D., 42Locust Ave., Wallington, NJ 07057.

patients with seborrheic dermatitis, as wellas therapeutic responses, imply this conclu-sion.^'-^ The same conclusion was drawnfrom culture results in patients with AIDS-associated seborrheic dermatitis.̂ **

Studies in which culture of seborrheicdermatitis was performed in infants four to16 weeks of age showed that P. ovale was adominant organism.^^^ P. ovale was foundwith significantly more frequency In infantswith seborrheic dermatitis than in infantswith atopic dermatitis or other infantiledermatoses, or in healthy infants.̂ ^

A neurogenic theory has been proposedfor the development of seborrheic dermati-tis that would account for its associationwith parkinsonism and other neurologicdisorders, and its induction by neurolepticdrugs that produce parkinsonian symp-toms."*"* The extent of involvement may beimpressive when confined to the areaaffected by syringomyelia or to the para-lyzed side in a hemiplegic patient. How-ever, no n euro transmitter chemicals havebeen identified that account for this phe-nomenon. It has been postulated that in-creased pooled sebum in affected areasmay be the cause.̂ ^

It has also been postulated that sebor-rheic dermatitis may reflect a nutritionaldeficiency. A deficiency of certain \dtaminsmay result in seborrheic dermatitis-likeeruptions.̂ """^^ However, no clear linkagehas been identified. A recent study^^ of theserum essential fatty-acid patterns from 30subjects witli infantile seborrheic dermati-tis suggested a transient impaired functionof the enzyme delta 6-desaturase.

Therapy

Treatment options for seborrheic der-matitis are listed in Table 2. Conventionaltherapy for adult seborrheic dermatitis ofthe scalp is a shampoo containing one ofthe four following compounds: salicylicacid (X-Seb T, Sebulex), selenium sulfide(Selsun, Exsel), coal tar (DHS Tar,Neutrogena T-Gel, Poiytar) or pyrithionezinc (DHS Zinc, Danex, Sebulon).^"-^^Each of these shampoos can be used two



TABLE 2

Treatment Options for Seborrheic Dermatitis

Preparations

ShampoosCoal tar

DHS Tar (0.5%)Neutrogena T/Gel (2%)Polytar (2.5%)Denorex (9%)

Extra Strength Denorex (12.5%)

ChloroxineCapitrol (2%)$

KetoconazoleNizoral (2%)|

Selenium sulfideSelsun Blue (1%)Exsel (2.5%)$Selsun (2.5%)$

Pyrithione zincDHS Zinc (2%)Danex (1%)Sebulon (2%)

Shampoo combinationsX-Seb T (10% coal tar, 4% saHcylic acid)Sebuiex (2% sulfur, 2% salicylic acid)

Topical preparationsCombination products

Sal-OU-T (10% coal tar, 6% salicylicadd)J

Sulfacetamide sodiumSebizon (10%)$

CorticosteroidsHytone (2.5%hydrocortlsone)$Lidex (0.05% fluocinonide)1:Synalar (0.01% fluocinolone)$Valisone (0.1% betamethasone)$

KetoconazoleNizoral (2%)$

Container cost

$ 7.00 (8 oz)6.00 (8 oz)t7.00 (6 oz)

43.00 (4 oz gel)42.00 (4 oz liquid)45.00 (4 oz)

16.00 (4 oz)

15.00 (4 oz)

3.00 (4 oz)13.00 (4 oz)12.00 (4 oz)

6.00 (6 oz)6.00 (4 oz)6.00 (4 oz)

6.00 (4 oz)6.00 (4 oz)

6.00 (2 oz hairdressing)

17.00 (2,5 oz lotion)

15.00 (30 g cream)17.00 (15 g cream)9.00 (15 g cream)

15.00 (15 g cream)

12.00 (15 g cream)

Usage

Use two to three times in first week.then once weekly as needed; leave onfor 5 minutes before rinsing away

Use twice weekly; leave on for 3minutes before rinsing away

Use two times weekly

Use two to three times weekly; leave onfor 2 to 3 minutes before rinsing away

Use twice weekly

Use twice weekly

Use twice weekly

Apply once or twice daily; allow bedtimeapplication to remain on overnight

Apply once or twice daily

Apply twice daily

•—Estimated cost to the pharmacist based on average wholesale prices, rounded to nearest dollar amount, in Redbook. Montvale, N.J.: Medical Economics Data, 1995. Cost to the patient will be higher, depending on prescriptionfiUingfee.t—Estimated price based on pharmacy cost in Kansas City, Mo., 1995.if.—Available by prescription only.

to three times a week. After application,shampoos should be left on the hair andscalp for at least five minutes, to ensurethat the medication reaches the scalpskin. Adults who have more severe casesmay use topical steroid lotions once or

July 1995

twice daily, often in addition to a med-icated shampoo.

The usual approach to infantile sebor-rheic dermatitis of the scalp is conserva-tive.' A mild, nonmedicated shampooshould be used at the start. If the mild

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shampoo is not helpful, a shampoo con-taining coal tar or a shampoo containing 2percent ketoconazole (Nizoral) or flucona-zole can be used to attack the presumedetiologic fungus P. ovale.^'^^'-^

In one series," a medicated shampoowas foimd to be helpful in 25 percent ofpatients with the often difficult-to-treatHIV-related seborrheic dermatitis. Aninfant's scalp can be painted with the com-mon dye eosin to achieve results as goodas those achieved with use of topicalsteroids, but without the potential side

Topical steroids are usually not neces-sary in infants and should be used withcare, since they may be associated withsignificant percutaneous absorption, localadverse effects and, rarely, suppressedadrenocortical function.̂ '̂ However, low-potency topical steroids are more likely tobe required for infantile or adult seborrhe-ic dermatitis of the flexural areas or forpersistent recalcitrant adult seborrheic der-matitis. In older children and adults,higher potency steroids may be used inlotion form on the scalp.

A new therapy is borage oil, a topicalform of gamma-linoleic acid, which hasbeen described as effective in infantile seb-orrheic dermatitis."^ In adolescents, thepotential of emotional distress brought onby severe seborrheic dermatitis, as well astfie danger of home remedies, must be keptin mind. In one case/^ a teenager apparent-ly used an organic solvent as self-medica-tion, resulting in a fatal intoxication.

A patient information handout on seborrheic der-matitis is provided on page 159.

Figure 2 (hiver photograph) reprinted with permis-sion from Cutis 1993:51:233-5.

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