Seborrheic Dermatitis - AKA Dandruff

Top Questions about Seborrheic Dermatitis

1. What is seborrheic dermatitis? Most people call it dandruff = redness/irritation on the skin that is often associated with a greasy scaling or flaking.  This condition can present as pink, hyperpigmented (darker) or hypopigmented (lighter) patches.

   
   

   

   Seborrheic dermatitis on the face

   
   
   
   

2. What causes seborrheic dermatitis? Like most organs in the body, the skin has its own microbiome.  One of the natural residents in the skin’s microbiome is a yeast called Malassezia.  A person can become sensitive to this yeast which in turn causes dandruff and irritation.  It is NOT an infection (thus not contagious) - it is a sensitivity to something that naturally lives on our skin. 

   
   

3. Where can you get seborrheic dermatitis on the body?  Most commonly, people get seborrheic dermatitis on the scalp but it can occur in the ears, the eyebrows, facial hair, around the creases in the nose, the chest and in babies it is common on the neck and in the diaper area.  

   

   Seborrheic dermatitis on scalp and face

   
   

4. What can make seborrheic dermatitis flare up? There are many factors that influence seborrheic dermatitis. Anything that can increase the growth of Malassezia can make seborrheic dermatitis worsen: humidity, sweating, poor hygiene. Furthermore, several health conditions make seborrheic dermatitis flare including: neurological conditions (stroke, Parkinson's) and HIV infection.  

   
   

5. Is there a cure for seborrheic dermatitis? Sadly, NO. We have great treatments but like any treatment, it works when you are using it. If you stop, the condition often flares up. There are very good maintenance routines to try and keep the flakes under control.

   
   

6. How do you treat seborrheic dermatitis? As many of us know, there are quite a few treatments for dandruff out there.  Here is a breakdown of the most effective treatments:

   
   

First, we will start with over the counter (OTC) treatments:

1. Zinc Pyrithione - this is an anti-fungal treatment - most often found as a 1% shampoo (i.e. Head and Shoulders). This should be used several times a week and left on for about 5 minutes in order to be effective.

2. Selenium Sulfide - works as an anti-fungal and anti-keratotic agent. Most often found as a 1% shampoo (i.e. Selsun Blue). This can also be prescribed at a higher percentage by your doctor.  It is used the same way the zinc pyrithione shampoos are - few times a week, leave in for ~5 min before rinsing.

3. Salicylic Acid or Tar - these are true keratolytic agents - they break down the flaking - they do nothing for the cause of the dandruff (the yeast). These are shampoos that come in several different percentages - and the regimen is as above.

4. Ketoconazole - this is an antifungal agent. The OTC version comes as a 1% shampoo (i.e. Nizoral) and I recommend using it 2-3 times weekly, leaving it on for about 5 min and then rinsing. 

   
   

   *Tip: if you are using any of these products on the face - I would limit the time to about 1-2 minutes 

   
   

There is also some data for Tea Tree Oil acting as an antifungal agent and thus Tea Tree Oil shampoos (~5%) can be effective for some patients.

Second, we will discuss prescription topical medications:

1. Ketoconazole - again this is an antifungal agent.  The prescription strength is 2% and it comes as a shampoo or a cream.  The cream is great for the face, chest and ears. This is the mainstay of seborrheic dermatitis treatment in my practice.  You use it 2-4 times a week initially, leaving on the shampoo for about 5 min before rinsing.  Since it is a little stronger than the OTC version, once the seborrheic dermatitis is controlled, usually you only need to use this 1-2 times a week.

   *Tip: If using the cream - you do not wash it off.

   *Tip: Safe for pediatric patients 

   
   

2. Ciclopirox - this is an antifungal agent. Typically this is prescribed as a shampoo or cream. You use it in the same fashion as the ketoconazole.

   
   

3. Topical Steroids - these are anti-inflammatory agents. In some cases, the inflammation is very strong.  In order to reduce the redness - we have to use topical steroids in combination with the antifungals.  This is usually always a solution, lotion, oil or cream.  Initially, you use this daily for up to 2 weeks. This is left on the skin - you do not rinse this off.

   *Tip: Safe for pediatric patients

   
   

Finally, there are a few systemic medications that can really help with stubborn or wide-spread seborrheic dermatitis:

1. Fluconazole - this is an antifungal treatment. For many patients where the topicals are just too much to remember, this is a very simple regimen. It is one pill (200 mg) weekly for about 4 weeks. 

*Tip: This is not a cure - so you will still need a maintenance topical regimen

I hope this helps navigate the very busy world of seborrheic dermatitis and please call Aislyn Dermatology (719-992-0127) if you are having trouble managing this condition.