VisualDx - Diagnosis Details - Adult Rash: Dermatitis, Seborrheic

690.1 – Seborrheic dermatitis

Seborrheic dermatitis is a common inflammatory papulosquamous disease of uncertain etiology associated with the sebaceous follicle regions of the body, face, scalp, and chest. The pathogenesis may be related to an abnormal immune response to Malassezia (Pityrosporum), a genus of yeast that commonly colonizes the skin. There are 2 clinical presentations: infantile, which is in the first 3 months of life and self-limited; and adult, with an estimated prevalence of up to 5%. Men tend to be affected more than women. There is often dryness, pruritus, erythema, and fine, greasy scaling in characteristic sites: the scalp, face (especially the eyebrows and nasolabial folds), anterior chest, external ear canal, posterior ears, eyelid margins (blepharitis), groin (scrotum or labia minora), and perianal area. One or multiple sites may be involved. Certain medications may cause seborrheic dermatitis to flare, such as gold compounds, phenothiazines, lithium, methyldopa, griseofulvin, psoralens, stanozolol, and interferon-alpha. Even with treatment, the disease tends to be chronic. Remissions and exacerbations should be expected.

Seborrheic dermatitis is often better in summer months and worse in the winter.

There is no apparent racial predilection. The condition may appear worse in men.

Look For

Loose, bran-like or greasy scales within erythematous, fine patches or plaques involving the scalp, eyebrows, eyelids, lips, ears, and skin folds, especially the nasolabial folds. It may also involve the anterior chest and umbilicus. Occasionally, crusted plaques are seen. The color may range from yellow-red to pink. Scale is less evident in intertriginous areas.

What is classically referred to as "dandruff" represents a mild form of this dermatitis.

Diagnostic Pearls

If scales are difficult to remove, consider psoriasis and examine the patient in characteristic locations (especially extensor surfaces).

Facial seborrheic dermatitis is often associated with rosacea.

Differential Diagnosis & Pitfalls

Perioral dermatitis
Rosacea
Tinea versicolor (trunk)
Allergic contact dermatitis
Irritant contact dermatitis
Nummular dermatitis (nummular eczema)
Tinea corporis
Psoriasis – The distinction between psoriasis and seborrheic dermatitis may be difficult at times, and there may be an overlap condition, sometimes referred to as "sebo-psoriasis" particularly when "greasy" scale is present in the scalp.
Candidiasis (intertriginous areas)
Intertrigo
Pityriasis rosea
Lichen simplex chronicus
Erythrasma
Impetigo
Atopic dermatitis
Darier's disease
Dermatomyositis – The eyelid erythema seen in this condition has a more violaceous hue.

Best Tests

This is usually a clinical diagnosis; a skin biopsy can be suggestive of but not diagnostic for this disease.

Consider a skin scraping with a KOH preparation to rule out tinea.

Consider HIV testing, especially in patients with risk factors / severe disease whose HIV status is unknown.

Zinc deficiency may lead to a seborrhea-like eruption; consider obtaining a zinc level, especially in patients with poor nutritional status.

Management Pearls

After lesions are controlled, the patient may be weaned from therapy, but they should restart therapy at the smallest manifestation of the disease.

Instruct the patient to avoid the use of harsh deodorant soaps. A soap substitute, such as Cetaphil®, is probably best.

Therapy

For the scalp:

Ketoconazole 2% shampoo – Apply to the wet scalp when first entering the shower. Use approximately twice weekly. The lather should also be used to cleanse the face and any other involved areas.
2% Pyrithione zinc shampoos
1% Ciclopirox shampoo twice weekly
For dense scalp scale, consider fluocinolone acetonide 0.01% in peanut oil – Apply nightly and then shampoo out in the morning. An alternative is overnight applications of Bakers P&S solution; apply nightly and shampoo out in the morning (120, 240 mL).

Alternative shampoos also include tar and salicylic acid-based preparations and 2.5% selenium sulfide shampoo.

Nonscalp disease:

Ketoconazole is the first-line treatment.

Ketoconazole cream twice daily (15, 30 gm) until clear

Although topical steroids may result in rapid clearing, they can induce rosacea. Thus, if necessary, only mild topical steroids should be used.

Use only mild topical steroids (class 6 or 7):

Desonide cream, lotion – apply twice daily (15, 30, 60 gm)
Hydrocortisone cream 2.5% – apply twice daily (1, 2 oz)

References

Fleischer AB. Diagnosis and management of common dermatoses in children: atopic, seborrheic, and contact dermatitis. Clin Pediatr (Phila). 2008 May;47(4):332-46. PubMed Id: 18057146

Plewig G, Jansen T. Seborrheic Dermatitis. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick's Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008:219-225.

Swinyer LJ, Decroix J, Langner A, Quiring JN, Blockhuys S. Ketoconazole gel 2% in the treatment of moderate to severe seborrheic dermatitis. Cutis. 2007 Jun;79(6):475-82. PubMed Id: 17713152

James WD, Berger TG, Elston DM. Seborrheic Dermatitis, Psoriasis, recalcitrant palmoplantar eruptions, Pustular Dermatitis, and Erythroderma. In: James WD, Berger TG, Elston DM, Odom RB, eds. Andrews' Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, PA: Saunders Elsevier; 2006:191-193.

Gupta AK, Batra R, Bluhm R, Boekhout T, Dawson TL. Skin diseases associated with Malassezia species. J Am Acad Dermatol. 2004 Nov;51(5):785-98. PubMed Id: 15523360

Gupta AK, Kogan N. Seborrhoeic dermatitis: current treatment practices. Expert Opin Pharmacother. 2004 Aug;5(8):1755-65. PubMed Id: 15264990

Gupta AK, Bluhm R, Cooper EA, Summerbell RC, Batra R. Seborrheic dermatitis. Dermatol Clin. 2003 Jul;21(3):401-12. PubMed Id: 12956195

Dreno B, Moyse D. Lithium gluconate in the treatment of seborrhoeic dermatitis: a multicenter, randomised, double-blind study versus placebo. Eur J Dermatol. 2002 Nov-Dec;12(6):549-52. PubMed Id: 12459525

Henderson CA, Taylor J, Cunliffe WJ. Sebum excretion rates in mothers and neonates. Br J Dermatol. 2000 Jan;142(1):110-1. PubMed Id: 10651703

Associated Findings

Appearance
No Acute Distress

Body Location
Breast
Cheek
Chest
Ear
Eyelids
Face
Female Genital
Forehead
Frontal Scalp
Inferior Eyelid
Inframammary Fold of Chest
Labia Majora
Male Genital
Nose
Occipital Scalp
Parietal Scalp
Post Auricular Scalp
Scrotum
Superior Chest
Superior Eyelid
Suprapubic/Mons Pubis
Temporal Scalp
Vertex Scalp

Configuration
Annular
Round

Distribution
Bilateral
Diaper Area
Intertriginous
Widespread Male Genital

Lesion
Scale Fine
Scaly Papule

Medications
Captopril
Cimetidine
Fluorouracil
Immunosuppressive
Interleukin-2
Nicotine
PUVA

Occupations
Military

Signs and Symptoms
No Fever (Afebrile, Apyrexial)
Pruritus (Itching)

Social History
Alcohol Abuse

Temporal
Developed Chronically Lasting Months to Years
Developed Steadily Over Weeks to Months

Medical History
Acquired Immune Deficiency Syndrome (AIDS)
Alcoholism
Down's Syndrome
Human Immunodeficiency Virus (HIV) Disease
Immunosuppression/Immunocompromised
Parkinson's Disease
Syringomyelia