Seborrheic dermatitis: Clinic, diagnosis and treatment
Medical editor: Dr. Pierre Schneider, Dermatologist, Saint-Louis Hospital, France.
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Dr. Pierre Schneider
Related topics
- Dryness / Atopy / Eczema
Key messages:
- Seborrheic dermatitis (SD) is a common non-infectious chronic inflammatory skin condition.
- It mostly affects men, with a higher prevalence in the elderly.
- Seborrheic dermatitis affects areas of the body rich in sebaceous glands: scalp, face (especially the T-zone), chest and back.
- The proliferation of the yeast Malassezia plays a major role in its development.
- Diagnosis is based on clinical examination.
- Treatment is essentially local (antifungal, anti-inflammatory and anti-seborrheic).
- Seborrheic dermatitis evolves by recurrent outbreaks favoured by stress.
- Seborrheic dermatitis is an inflammatory skin condition characterized by red, scaly, itchy patches located preferentially in areas rich in sebaceous (seborrheic) glands: scalp, face – mainly the T-zone –, chest area, and back1.
- It is a very common benign condition that affects between 1 and 8% of the general population, with a higher prevalence in men and the elderly2.
- Like atopic dermatitis, seborrheic dermatitis has wide geographic disparities1.
- In France, it affects 1-3% of adolescents and adults6.
- SD can have a strong impact on the quality of life of patients: discomfort, stigmatization, loss of self-esteem, and a limited social life2.
- The exact causes of seborrheic dermatitis are not fully understood, but a combination of factors contribute to its development1.
The causes of seborrheic dermatitis are multifactorial and involve the interaction of three factors:
- The presence on the skin of yeast of the genus Malassezia.
- Sebaceous secretions.
- The immunological profile.
The role of Malassezia yeast in SD1,5,8
- This type of yeast is commonly found on the skin. Its presence alone is not enough to trigger seborrheic dermatitis.
- However, in some individuals with an impaired skin barrier, the metabolites released by Malassezia on the scalp are responsible for the skin scaling observed in SD.
- The presence of Malassezia in these individuals also causes local inflammation associated with itching.
- The strong correlation between the reduction of Malassezia and the reduction of symptoms associated with SD makes it the preferred target for the treatment of this condition.
Find out more:
In addition to its involvement in the development of seborrheic dermatitis, Malassezia yeast is associated with numerous skin diseases such as pityriasis versicolor and folliculitis3.
The role of sebaceous secretions in SD4,8
A set of arguments identifies sebaceous secretions as participating in the physiopathology of SD:
- More prevalent in adolescence (more active sebaceous glands).
- Lesions due to SD localized in areas of the body rich in sebaceous glands.
- Lipid composition of the skin surface of men with SD differs from that of unaffected controls.
- Greater presence of Malassezia in areas of greatest sebaceous secretion.
While these arguments support a role for sebaceous secretions in the development of SD, the details of their involvement remain unknown.
Immune factors involved in SD4
- The involvement of the immune system is demonstrated in particular by the much higher frequency of SD in immunocompromised patients (organ transplants, HIV, chronic alcoholic pancreatitis, hepatitis C and various malignancies), with rates of up to 83%, compared to 1-3% in the general population.
- However, the details of the mechanism of action are yet to be identified.
Other factors
- Seborrheic dermatitis is more common in men than in women, and the incidence of SD increases in males during adolescence and young adulthood. This suggests an important role for hormones (especially androgens) in its development4.
- Stress also plays an important role in the onset of relapses without correlating with a depressive state of the patients. On the other hand, patients in whom stress is likely to cause a relapse, have a higher anxiety score than other patients with SD10.
- The involvement of genetic factors in SD is less documented than in psoriasis or atopic dermatitis.
- A recent cross-sectional study (2018) including 4,050 participants, 609 of whom had SD (15%), nevertheless identified a correlation between SD and genetic variations that may be involved in inflammation, immunity, or certain skin properties7.
The clinical presentation of seborrheic dermatitis is different in infants and in adults.
Newborn and infant11,17
Infantile seborrheic dermatitis appears towards the end of the 1st or 2nd month and lasts approximately 4 to 6 months. It appears as squamous erythema or crusty eruptions. It can present itself:
- As in adults, in the form of bipolar involvement (scalp and face): greasy, thick, white and yellowish scales (cradle cap).
Fig 1,2: Cradle cap
- In the breech area: breech dermatitis.
- In the folds of the neck and armpits: greasy scales of the axillary folds (possible).
- Absence of pruritus.
- A generalized erythroderma (called Leiner-Moussous) may appear on rare occasions. It often has a positive outcome.
Adult11,17
- Non-infiltrated, bilateral and symmetrical erythemato-squamous lesions.
- Facial lesions present in 88% of patients, in the form of erythematous patches that may be covered with greasy scales on the nasolabial folds, eyebrows, glabella, and the anterior edge of the scalp. In men, the beard and moustache may be the site of lesions.
Fig: Mediofacial seborrheic dermatitis
- Scalp lesions affect 70% of patients. Most of the time, they are not very severe (pityriasis capitis) but may cause itching.
- Involvement of the trunk in about 27% of patients, in the form of annular or circular plaques on the presternal region.
- Extensive or severe forms:
- Lesions on the chin and ciliary margins of the eyelids (seborrheic blepharitis) are possible.
- Pityriasis rosea: severe form of seborrheic dermatitis of the scalp, with the appearance of a helmet surrounding tufts of hair.
- The diagnosis of seborrheic dermatitis is clinical.
- The most compelling clinical clue is the predominant location of lesions in areas rich in sebaceous glands (face and scalp in particular) as well as the appearance of the lesions and their evolution over time11,17.
Clark GW, Pope SM, Jaboori KA. Diagnosis and treatment of seborrheic dermatitis. Am Fam Physician. 2015 Feb 1;91(3):185-90. PMID: 25822272.
Fig 1: Atopic dermatitis; Fig 2: Candidiasis; Fig 3: Impetigo, Fig 4: Nummular dermatitis; Fig 5: Pityriasis rosea
- Complications of seborrheic dermatitis are rare. They mainly involve the intertriginous areas and the eyelids, which can become infected during a flare-up, as well as the breech area of infants17.
- Severe and extensive seborrheic dermatitis is also common in patients with Parkinson's disease: 18-59% of patients with Parkinson's have SD14.
- SD may also reflect excessive alcohol consumption15 or HIV infection16. In HIV-infected patients, the prevalence of SD ranges from 30% to 83%. It is in these forms that the role of Malassezia is most clearly suspected.
- Severe and/or chronic seborrheic dermatitis should lead to HIV testing.
- Seborrheic dermatitis evolves in flare-ups for which there is no curative treatment.
- Management consists of alleviating the symptoms but requires good compliance to avoid relapses. Maintaining the patient in a state of remission will require alternating treatments11.
- As background treatment, mild products should be used for cleansing, and shampoos with zinc pyrithione, piroctone olamine, ketoconazole or selenium sulfide should be used. These SD-specific shampoos have anti-inflammatory and/or antifungal activity and may be sufficient for simple dandruff conditions.
- Therapeutic management will aim to:
- Reduce Malassezia colonization with antifungal treatments.
- Limit the inflammation.
- Limit sebum secretion.
- In moderate forms, the initial treatment with local antifungal agents or lithium gluconate should be continued for 2 to 4 weeks, and then kept as sequential maintenance treatment11,12.
- In highly inflammatory forms, it is recommended to use topical corticosteroids of moderate strength for a few days. Subsequently, a more effective and better tolerated non-corticoid treatment may be considered11.
- In case of Leiner-Moussous erythroderma: prescription of topical ketoconazole.
What should be applied in case of diaper rash?
Diaper rash can have several causes. Some of the most common are:
- Prolonged contact with urine and stool.
- Irritation due to rubbing with the diaper.
- Sensitivity to hygiene products...
When seborrheic dermatitis is suspected, the therapeutic management is the same as for adults: application of topical antifungals associated with a short treatment of dermocorticoids, if necessary.
Is Vaseline recommended to remove cradle cap?
Vaseline ointment is indeed recommended for removing cradle cap: apply it to the baby's head in the evening and wash the next day with a mild shampoo. The scales can then be removed more easily13.
- Clark GW, Pope SM, Jaboori KA. Diagnosis and treatment of seborrheic dermatitis. Am Fam Physician. 2015 Feb 1;91(3):185-90. PMID: 25822272.
- Zander N, Sommer R, Schäfer I, Reinert R, Kirsten N, Zyriax BC, Maul JT, Augustin M. Epidemiology and dermatological comorbidity of seborrhoeic dermatitis: population-based study in 161 269 employees. Br J Dermatol. 2019 Oct;181(4):743-748. doi: 10.1111/bjd.17826. Epub 2019 Jul 17. PMID: 30802934.
- Gaitanis G, Magiatis P, Hantschke M, Bassukas ID, Velegraki A. The Malassezia genus in skin and systemic diseases. Clin Microbiol Rev. 2012 Jan;25(1):106-41. doi: 10.1128/CMR.00021-11. PMID: 22232373; PMCID: PMC3255962.
- Dessinioti C, Katsambas A. Seborrheic dermatitis: etiology, risk factors, and treatments: facts and controversies. Clin Dermatol. 2013 Jul-Aug;31(4):343-351. doi: 10.1016/j.clindermatol.2013.01.001. PMID: 23806151.
- DeAngelis YM, Gemmer CM, Kaczvinsky JR, Kenneally DC, Schwartz JR, Dawson TL Jr. Three etiologic facets of dandruff and seborrheic dermatitis: Malassezia fungi, sebaceous lipids, and individual sensitivity. J Investig Dermatol Symp Proc. 2005 Dec;10(3):295-7. doi: 10.1111/j.1087-0024.2005.10119.x. PMID: 16382685.
- Qu'est-ce que la dermatite séborrhéique de l'adulte ? | ameli.fr | Assuré
- Sanders MGH, Pardo LM, Uitterlinden AG, Smith AM, Ginger RS, Nijsten T. The Genetics of Seborrheic Dermatitis: A Candidate Gene Approach and Pilot Genome-Wide Association Study. J Invest Dermatol. 2018 Apr;138(4):991-993. doi: 10.1016/j.jid.2017.11.020. Epub 2017 Dec 2. PMID: 29203360.
- Borda LJ, Perper M, Keri JE. Treatment of seborrheic dermatitis: a comprehensive review. J Dermatolog Treat. 2019 Mar;30(2):158-169. doi: 10.1080/09546634.2018.1473554. Epub 2018 May 24. PMID: 29737895.
- Misery L; La dermatite séborrhéique de l’enfant. Journal de pédiatrie et de puériculture (2020) 33, 174—176. doi :10.1016/j.jpp.2020.02.003.
- Misery L, Touboul S, Vinçot C, Dutray S, Rolland-Jacob G, Consoli SG, Farcet Y, Feton-Danou N, Cardinaud F, Callot V, De La Chapelle C, Pomey-Rey D, Consoli SM; Pour le Groupe Psychodermatologie. Stress et dermatite séborrhéique [Stress and seborrheic dermatitis]. Ann Dermatol Venereol. 2007 Nov;134(11):833-7. French. doi: 10.1016/s0151-9638(07)92826-4. PMID: 18033062.
- Item 109 – UE 4 Dermatoses faciales : acné, rosacée, dermatite séborrhéique (cedef.info)
- Dréno B, Blouin E, Moyse D. Gluconate de lithium gel à 8 p. 100 dans le traitement de la dermatite séborrhéique [Lithium gluconate 8% in the treatment of seborrheic dermatitis]. Ann Dermatol Venereol. 2007 Apr;134(4 Pt 1):347-51. French. doi: 10.1016/s0151-9638(07)89189-7. PMID: 17483754.
- Le traitement des croûtes de lait - VIDAL
- Tomic S, Kuric I, Kuric TG, Popovic Z, Kragujevic J, Zubonja TM, Rajkovaca I, Matosa S. Seborrheic Dermatitis Is Related to Motor Symptoms in Parkinson's Disease. J Clin Neurol. 2022 Nov;18(6):628-634. doi: 10.3988/jcn.2022.18.6.628. PMID: 36367060; PMCID: PMC9669556.
- Jain NP, Shao K, Stewart C, Grant-Kels JM. The effects of alcohol and illicit drug use on the skin. Clin Dermatol. 2021 Sep-Oct;39(5):772-783. doi: 10.1016/j.clindermatol.2021.05.005. Epub 2021 May 21. PMID: 34785005.
- Chatzikokkinou P, Sotiropoulos K, Katoulis A, Luzzati R, Trevisan G. Seborrheic dermatitis - an early and common skin manifestation in HIV patients. Acta Dermatovenerol Croat. 2008;16(4):226-30. PMID: 19111149.
- Tucker D, Masood S. Seborrheic Dermatitis. StatPearls, StatPearls Publishing, 2021.
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