CPD 68: SEBORRHOEIC DERMATITIS Biography - Eamonn Brady MPSI is the owner of Whelehans Pharmacy in Mullingar. He graduated from the Robert Gordon University in Aberdeen in 2000 with a First Class Honours MPharm degree in pharmacy. He worked for Boots in the UK before moving back to Ireland in 2002. He bought Whelehans Pharmacy in Mullingar in 2005. He undertakes clinical training for nurses and other healthcare professional in the midlands and undertakes talks on health and pharmacy related subjects. Contact Eamonn at 04493 34591 if you wish him to undertake training or a health talk.
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The term seborrhoeic dermatitis is derived from the distribution of this disorder, in which erythematous, scaly patches develop in areas that are rich in sebaceous glands, such as the scalp, face, and upper trunk. The term “seborrhoea” refers to excess oil secretion, although this finding is not uniformly present in patients with seborrhoeic dermatitis.1,2 It is more likely to affect men than women. It is commonly aggravated by changes in humidity, changes in seasons, trauma (eg, scratching), or emotional stress. The usual onset occurs with puberty. It peaks at age 40 years and is less severe in older people. Approximately 1 to 3 percent of adults suffer from seborrhoeic dermatitis.3 Dandruff is a mild form of seborrhoeic dermatitis and is estimated to affect 15 to 20 percent of the population. CAUSE The cause of seborrhoeic dermatitis is unknown. There is evidence that malassezia fungi may have an influence.4 Malassezia are lipid dependent organisms which are normally present on the skin surface. However, in patients suffering from seborrhoeic dermatitis, there is evidence of an abnormally high level of malassezia fungi on the skin which leads to an inflammatory response.5 This theory is supported by the fact that seborrhoeic dermatitis responds to antifungal treatment. SYMPTOMS Seborrhoeic dermatitis presents as erythema and scale, with some itch. Seborrhoeic dermatitis most commonly affects the lateral sides of the nose and the nasolabial folds
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Seborrhoeic Dermatitis INTRODUCTION
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(skin folds that run from each side of nose to corner of mouth), eyebrows, glabella (space between eyebrows and above the nose) and scalp. The chest, upper back and axillae (armpits) are less commonly affected. It tends to be worse under moustaches and beards in men so shaving is recommended. Cradle cap is a form of seborrhoeic dermatitis found in infants. Cradle cap manifests as greasy patches of scaling on the scalp of infants between the second week and sixth month of life. Untreated, it usually resolves at 8 months. It’s generally non-pruritic and doesn’t bother the infant, though it can be a stressor for parents. As with seborrhoeic dermatitis in adults, researchers have noted a potential link between cradle cap and increased concentrations of the yeast Malassezia furfur, but a causative mechanism has not been identified. PATHOPHYSIOLOGY The pathophysiology of seborrhoeic dermatitis is not completely understood but the mechanisms of effective therapies coupled with results of biomolecular studies provide clues about the causes. The redness, itching, and scaling associated with seborrhoeic dermatitis are caused by changes in skin cell functioning.19, 20 Malassezia fungi appear to cause a nonspecific immune response that begins the cascade of skin changes that occur in seborrhoeic dermatitis.19 Malassezia is a normal component of skin flora, but in those with seborrheic dermatitis, the fungi invade the stratum corneum, releasing lipases that result in free fatty acid formation and cause the inflammatory process to begin.21 Malassezia thrive in high-lipid environments,
60 Second Summary Seborrhoeic dermatitis is characterised by erythematous, scaly patches in areas rich in sebaceous glands, such as the scalp, face, and upper trunk. The cause of seborrhoeic dermatitis is unknown. There is evidence that malassezia fungi may have an influence. It is more likely to affect men than women. It is commonly aggravated by changes in humidity, changes in seasons, trauma (eg, scratching), or emotional stress. The usual onset occurs with puberty. It peaks at age 40 years and is less severe in older people. Approximately 1 to 3 percent of adults suffer from seborrhoeic dermatitis. Dandruff is a mild form of seborrhoeic dermatitis and is estimated to affect 15 to 20 percent of the population. Diagnosis is generally by physical examination. Certain other conditions display similar symptoms and should be discounted; they include psoriasis, atopic dermatitis, and impetigo. Treatment For mild to moderate seborrhoeic dermatitis, including dandruff, medicated shampoos containing salicylic acid or selenium sulphide are often effective treatment options. Combination treatments are useful in patients who do not respond to a single agent. Medicated shampoos containing ketoconazole, ciclopirox, selenium sulphide, coal tar, salicylic acid and zinc pyrithione should be used at twice weekly for at least a month and if necessary, indefinitely. Ketoconazole 2% shampoo is the most effective treatment for moderate to severe seborrhoeic dermatitis. Combining ketoconazole with a steroid solution is effective where inflammation is a problem. Corticosteroids should never be used routinely. Ciclospirox shampoo is also very effective for moderate to severe seborrhoeic dermatitis.
CPD 68: SEBORRHOEIC DERMATITIS
so the presence of free fatty acids enhances the growth of the fungi. The inflammation causes stratum corneum hyperproliferation (scaling) and incomplete corneocyte differentiation, which alters the stratum corneum barrier and impairs its function, thus increasing access for Malassezia and allowing water to more readily leave the cells.22 Based on the current understanding of the pathophysiology of the condition, the treatments for seborrhoeic dermatitis make clinical sense. Keratolytics (sulfur and salicylic acid) help remove the outer layers of the hyper-proliferating stratum corneum.22 Coal tar is thought to decrease the rate of stratum corneum production.22 Antifungals decrease the Malassezia population, whereas anti-inflammatories such as corticosteroids and calcineurin inhibitors decrease the inflammatory response. The severity of symptoms can be affected by stress and sun exposure, and often has a variable course despite treatment.
similar symptoms should be discounted. On the scalp it should be differentiated from psoriasis, atopic dermatitis, and impetigo. On the face, rosacea, contact dermatitis, psoriasis, and impetigo should be discounted and on the trunk, pityriasis versicolor and pityriasis rosea must be discounted. Diagnosis is generally by physical examination. Seborrhoeic dermatitis is a clinical diagnosis based on the location and appearance of lesions. In infants, it may present as thick white or yellow greasy scales on the scalp; it is usually benign and resolves spontaneously. In adolescents and adults, seborrheic dermatitis typically presents as flaky, greasy, erythematous patches on the scalp (See Figure 1), nasolabial folds (See Figure 2), ears, eyebrows (See Figure 3 and 4), anterior chest, or upper back. The diagnosis can be challenging in patients with darker skin.
SIMILAR CONDITIONS WHICH SHOULD NOT BE CONFUSED WITH SEBORRHOEIC DERMATITIS
Depending on the part of the body affected, certain other conditions which display
Psoriasis- this is a condition of unknown cause. About 80% of people living with
psoriasis have plaque psoriasis, also called “psoriasis vulgaris.” Plaque psoriasis causes patches of thick, scaly skin that may be white, silvery, or red. Unlike seborrhoeic dermatitis, these patches can develop anywhere on the skin. The most common areas to find plaques are the elbows, knees, lower back, and scalp. The margins tend to be less sharply demarcated in seborrhoeic dermatitis than in psoriasis. Atopic Dermatitis- Atopic dermatitis is a chronic skin condition that runs in families. It often starts out as dry, extremely itchy skin. The rash may become very red, swollen and sore. The more you scratch it, the worse it generally gets. A clear fluid may leak from the rash. Eventually, the rash will crust over and start to scale. Common places for the rash are in the elbow creases, behind the knees, on the cheeks, and on the buttocks. Impetigo- Impetigo is a skin infection caused by the common Staphylococcus bacteria. The infection causes eruptions of blisters and scabs on the skin. It usually occurs in children or adolescents. Those with existing eczema are more at risk of contracting the infection. While not a
CPD 68: SEBORRHOEIC DERMATITIS serious condition in itself, impetigo is highly contagious. Impetigo first appears as a small patch of itchy skin that becomes red or inflamed. Small blisters develop, which may weep a yellow fluid. This fluid becomes crusty, forming scabs, and new blisters may form. The infection is typically localised and confined to the face, and around the mouth and nose, although it may also appear on the legs. Rosacea- Rosacea is a skin condition of the face that tends to run in fair-skinned families and tends to occur in people who blush easily. Symptoms usually begin in adults between the ages of 30 and 60. Its cause is unknown. It often begins as redness that looks like a blush across the nose, cheeks, chin or forehead. As time goes on, red pimples and pus-filled bumps may appear. Some people also notice small blood vessels across their nose and cheeks. In some people, the skin of the nose may become red and thick. Pityriasis rosea- pityriasis rosea is a scaly, reddish-pink skin rash. It can look like eczema or psoriasis. It is most common in children and young adults, and usually occurs in spring and autumn. Pityriasis versicolor- Pityriasis versicolor is a rash caused by yeast called ‘pityrosporum’. It normally affects people at puberty probably because of hormonal changes and increased sebum production. In sufferers, pityrosporum multiplies on their skin more than usual, which leads to a rash. The rash usually starts as small pale patches. At first these usually appear on the chest, neck, or upper arms. The rash sometimes spreads to the abdomen, thighs, and back. More patches may appear, and patches next to each other may join together. The affected skin may become slightly scaly. The rash is usually pale, and is barely noticeable if you are fair-skinned. Affected areas do not tan, and therefore the rash becomes more obvious on tanned skin. The pale patches are more obvious if you have dark skin. SEBORRHOEIC DERMATITIS ASSOCIATED WITH DISEASE HIV infection- Seborrhoeic dermatitis is common in patients with HIV infection. Before the introduction of effective antiretroviral therapies, up to 40 percent of HIV positive patients and 80 percent of those with AIDS had seborrhoeic dermatitis.6,7 Malassezia infection does not appear to be the cause of seborrhoeic dermatitis in HIV positive patients.8 The possibility of HIV infection should be considered in patients presenting with new onset severe seborrhoeic dermatitis. Neurological disorders — Seborrhoeic dermatitis is more common in patients with Parkinson’s disease. Other neurological disorders, including mood disorders and
tardive dyskinesia, are also frequently associated with seborrhoeic dermatitis.3,9 TREATMENT Seborrhoeic dermatitis of the scalp (including Dandruff) Daily shampooing of the scalp with a medicated shampoo helps control scaling and pruritus. For best results, the shampoo should be left in place for five to ten minutes before rinsing. Examples of classes of shampoos available include keratolytic shampoos, regulators of keratinisation, antimicrobial agents and antifungal agents. Keratolytic agents soften, dissolve and release adherent scale seen in dandruff. The mechanism of keratolytic agents is not fully understood. Keratolytic agents include salicylic acid and sulphur. Preparations containing salicylic for the treatment of seborrhoeic dermatitis include Capasal® shampoo and Cocois® ointment. Cocois® ointment also contains sulphur and Coal tar. The fact that Cocois® has to be kept on the scalp for an hour before shampooing limits its use due to the fact this regime is less convenient than other therapeutic shampoos available. Regulators of keratinisation include zinc and tar. Zinc pyrithione (Head and Shoulders®) is thought to control dandruff by normalising epithelial keratinisation, sebum production or both. Coal tar has been classically used to treat psoriasis, however it is also effective in treating dandruff. Problems of staining, its strong odour and messiness make tar products second line for most patients. Tar products work by dispersing scales which results in less Malassezia colonisation. There are many coal tar products on the market including T-gel® shampoo and Polytar® liquid.
Combination products of coal tar and other agents such as salicylic acid are common. (Eg) Capasal®. Antimicrobial agents such as selenium sulphide control dandruff via an antipityrosporum effect rather than by an antiproliferative effect. Selsun® is available over the counter in Ireland and is also used to treat pityriasis versicolor because of its effectiveness on the pityrosporum yeast. Imidazole topical antifungals such as ketoconazole act by blocking the biosynthesis of ergosterol, the primary sterol derivative of the fungal cell membrane. Hydroxypyridones such as ciclopirox exert their anti-fungal effect by interfering with fungal cell membrane integrity and cell respiratory processes. Shampoos containing the antifungal agents’ ketoconazole or ciclopirox are effective in the control of scalp seborrhoeic dermatitis. One study compared the use of ketoconazole 2% shampoo with selenium sulphide 2.5 % shampoo in patients with seborrhoeic dermatitis.10 Both were significantly better than placebo and similarly effective for reducing irritation and itching; ketoconazole shampoo was better tolerated. Brands of ketoconazole shampoo available in Ireland include Nizoral® and Ketozol®. Another large randomised trial found that ciclopirox shampoo was superior to placebo.11 Stieprox® shampoo is the brand name for ciclospirox available in Ireland. Low potency corticosteroids may be used if other treatments prove ineffective. They should be used daily until improvement is seen. They should not be used for longer than a few days in seborrhoeic dermatitis. Alcohol-based solutions, gel, or foam preparations are most effective on the scalp. Locoid® scalp application (medium potency), Elocon® scalp application (potent) and Betnovate® Scalp application (potent) are
CPD 68: SEBORRHOEIC DERMATITIS used short term for non scalp seborrhoeic dermatitis if other treatments fail. Creams or lotions are best tolerated on the face. Hydrocortisone 1% cream should be the first choice corticosteroid in seborrhoeic dermatitis due to its mild potency. Systemic fluconazole may help if seborrhoeic dermatitis is severe or unresponsive. The role of topical metronidazole agents in the therapy of seborrhoeic dermatitis has not been proven. REFERENCES treatment options available in Ireland. Topical corticosteroids may hasten recurrences, may cause dependence because of a rebound effect, and are discouraged except for short-term use. Tea tree oil is a natural remedy derived from the leaves of an Australian tree called melaleuca alternifolia. It is often used for the treatment of dandruff. A trial that randomly assigned 126 people aged 14 or older with dandruff to four weeks of tea tree oil 5 percent shampoo or placebo found tea tree oil was significantly better.12 However, only one patient in each group achieved a complete response. There were no significant adverse events in this study; however, products containing tea tree oil have been associated with cutaneous allergic reactions,13,14 and tea tree oil may have oestrogenic and anti-androgenic effects.15 The role of tea tree oil in the treatment of dandruff is uncertain. Cradle cap General guidance is regular washing with baby shampoo followed by gentle brushing although no trials could be found to show its efficacy for infants. Alternatively, softening the scale with mineral oil (such as olive oil), followed by gentle brushing and shampooing is an alternative approach. Ketoconazole 2% shampoo or cream once a day has been shown to be effective; topical corticosteroids must be avoided.1 Non-scalp seborrhoeic dermatitis Antifungals, topical corticosteroids, or combinations of the two are the standard treatments for non scalp seborrhoeic dermatitis. Topical and systemic antifungal agents are also effective. Ketoconazole shampoo is approved for this indication. Benefit has been shown with ketoconazole cream16,17 and oral terbinafine.18 As with seborrhoeic dermatitis of the scalp, low potency corticosteroids should only be
1. Burton, JL, Pye, RJ. Seborrhoea is not a feature of seborrhoeic dermatitis. Br Med J (Clin Res Ed) 1983; 286:1169. 2. Naldi, L, Rebora, A. Clinical practice. Seborrheic dermatitis. N Engl J Med 2009; 360:387. 3. Gupta, AK, Bluhm, R. Seborrheic dermatitis. J Eur Acad Dermatol Venereol 2004; 18:13. 4. Dawson, TL Jr. Malassezia globosa and restricta: breakthrough understanding of the etiology and treatment of dandruff and seborrheic dermatitis through whole-genome analysis. J Investig Dermatol Symp Proc 2007; 12:15. 5. DeAngelis, YM, Gemmer, CM, Kaczvinsky, JR, et al. Three etiologic facets of dandruff and seborrheic dermatitis: Malassezia fungi, sebaceous lipids, and individual sensitivity. J Investig Dermatol Symp Proc 2005; 10:295.
11. Shuster, S, Meynadier, J, Kerl, H, Nolting, S. Treatment and prophylaxis of seborrheic dermatitis of the scalp with antipityrosporal 1% ciclopirox shampoo. Arch Dermatol 2005; 141:47. 12. Satchell, AC, Saurajen, A, Bell, C, Barnetson, RS. Treatment of dandruff with 5% tea tree oil shampoo. J Am Acad Dermatol 2002; 47:852. 13. Van der, Valk PG, de Groot, AC, Bruynzeel, DP, et al. [Allergic contact eczema due to ‘tea tree’ oil]. Ned Tijdschr Geneeskd 1994; 138:823. 14. Knight, TE, Hausen, BM. Melaleuca oil (tea tree oil) dermatitis. J Am Acad Dermatol 1994; 30:423. 15. Henley, DV, Lipson, N, Korach, KS, Bloch, CA. Prepubertal gynecomastia linked to lavender and tea tree oils. N Engl J Med 2007; 356:479. 16. Pierard, GE, Pierard-Franchimont, C, Van Cutsem, J, et al. Ketoconazole 2% emulsion in the treatment of seborrheic dermatitis. Int J Dermatol 1991; 30:806. 17. Van Cutsem, J, Van Gerven, F, Fransen, J, et al. The in vitro antifungal activity of ketoconazole, zinc pyrithione, and selenium sulfide against Pityrosporum and their efficacy as a shampoo in the treatment of experimental pityrosporosis in guinea pigs. J Am Acad Dermatol 1990; 22:993.
6. Eisenstat, BA, Wormser, GP. Seborrheic dermatitis and butterfly rash in AIDS. N Engl J Med 1984; 311:189.
18. Scaparro, E, Quadri, G, Virno, G, et al. Evaluation of the efficacy and tolerability of oral terbinafine (Daskil) in patients with seborrhoeic dermatitis. A multicentre, randomized, investigator-blinded, placebocontrolled trial. Br J Dermatol 2001; 144:854.
7. Mathes, BM, Douglass, MC. Seborrheic dermatitis in patients with acquired immunodeficiency syndrome. J Am Acad Dermatol 1985; 13:947.
19. Gaitanis G, Magiatis P, Hantschke M, Bassukas ID, Velegraki A. The Malassezia genus in skin and systemic diseases. Clin Microbiol Rev. 2012;25(1):106–141.
8. Wikler, JR, Nieboer, C, Willemze, R. Quantitative skin cultures of Pityrosporum yeasts in patients seropositive for the human immunodeficiency virus with and without seborrheic dermatitis. J Am Acad Dermatol 1992; 27:37.
20. Viodé C, Lejeune O, Turlier V, et al. Cathepsin S, a new pruritus biomarker in clinical dandruff/seborrhoeic dermatitis evaluation. Exp Dermatol. 2014;23(4):274– 275.
9. Chen, TM, Fitzpatrick, JE. Unilateral seborrheic dermatitis after decompression of Chiari I malformation and syringomyelia. J Am Acad Dermatol 2006; 55:356. 10. Danby, FW, Maddin, WS, Margewwon, L, Rosenthal, D. A randomized, double-blind, placebo-controlled trial of ketoconazole 2% shampoo versus selenium sulfide 2.5% shampoo in the treatment of moderate to severe dandruff. J Am Acad Dermatol 1993; 29:1008.
21. Schwartz JR, Messenger AG, Tosti A, et al. A comprehensive pathophysiology of dandruff and seborrheic dermatitis - towards a more precise definition of scalp health. Acta Derm Venereol. 2013;93(2):131–137. 22. Sanfilippo A, English JC. An overview of medicated shampoos used in dandruff treatment. Pharm Ther. 2006;31:396–400.