Core Training

Seborrhoeic dermatitis

S
eborrhoeic dermatitis, also assessment, diagnosis and management of are lipophilic and are often distributed (but
known as seborrhoeic eczema, is seborrhoeic dermatitis with a particular focus not limited to) the sebum (lipid) rich areas of
a common chronic inflammatory on the adult form of the disease. the scalp, face and trunk. The production of
skin disorder with a prevalence lipase by these organisms and the subsequent
between 1 and 10% of the general Aetiology release of arachidonic acid is thought to cause
adult population (Naldi, 2010; Bukvic et al, Numerous risk factors have been implicated cutaneous inflammation (Kim, 2009).
2012). Men are more likely to be affected in the development of seborrhoeic The link between sebum overproduction
than women, with the peak incidence in the dermatitis. It is important to note that it is and the hyperproliferation of Malassezia
third and fourth decades of life. the interaction between multiple factors that is tenuous at best, as individuals with
Seborrhoeic dermatitis is characterized determines an individual’s susceptibility to normal sebum production can still manifest
by a red scaly rash affecting the sebaceous the development of seborrhoeic dermatitis. seborrhoeic dermatitis. This suggests
(oil producing) areas of the face, scalp, upper alternative factors such as sebum composition
chest and back. The axillae and genital region Malassezia yeasts or immunological predisposition may be to
may also be involved in some cases (Figure There is a correlation between Malassezia blame (Kim, 2009). What is clear is that
1, Table 1). An infantile form also exists spp. and the development of seborrhoeic cases of seborrhoeic dermatitis often respond
and is often self limiting, although if this is dermatitis (Naldi, 2010; Del Rosso, 2011). well to antifungal therapy, leading to the
persistent it can develop into a more chronic Malassezia spp. are a type of fungus naturally notion that these commensal yeasts play an
and diffuse form of the condition (Berk and found on the skin surfaces of humans. It is important role in its development (Kim,
Scheinfeld, 2010; Del Rosso, 2011). This thought that specific species are implicated 2009; Del Rosso, 2011).
article provides a stepwise approach to the in the development of certain conditions
including pityriasis versicolor, Malassezia Immune response
Figure 1. Body sites commonly affected by folliculitis and possibly atopic dermatitis. Immune dysfunction is thought to play a role in
seborrhoeic dermatitis.
Species associated with the development of the development of seborrhoeic dermatitis by
seborrhoeic dermatitis include M. restricta allowing the hyperproliferation of Malassezia
and M. globosa (Levin, 2009). Malassezia spp. (Amado et al, 2013). Seborrhoeic dermatitis

Table 1. The clinical features of seborrhoeic dermatitis and dandruff in adults

Scalp From mild desquamation to honey-coloured crusts attached to the scalp and hair,
leading to a non-scarring alopecia. May reach into forehead as a scaly erythematous
border known as ‘corona seborrheica’
Face or Forehead, eyebrows, glabella or nasolabial folds. May spread to malar regions and
retro-auricle cheeks in butterfly distribution
area
Eyelids: yellowish scaling between eye lashes. Can lead to blepharitis with
honey-coloured crusts on free margin
Retro-auricular area: crusting, oozing and fissures. May expand to external canal, with
marked itching on occasionally secondary infection (otitis externa)
Upper chest Petaloid type (common): small, reddish follicular and peri-follicular papules with oily
scales at onset that become patches resembling a medallion (flower petals)
Dr N Ijaz, Specialty Doctor in Dermatology, Pityriasiform type: widespread 5–15 mm oval-shaped, scaly macules and patches.
Dermatology Department, Salford Royal Distributed along the skin tension lines (similar to extensive pityriasis rosea). New
Hospital, Manchester M6 8HD eruptions can continue for >3 months. Commonly on face and intertriginous areas
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Dr D Fitzgerald, Consultant, Dermatology

Department, Salford Royal Hospital, Body folds Moist, macerated appearance with erythema at the base and periphery on axillae,
Manchester umbilicus, breast fold, genital or inguinal areas. May progress to fissures and secondary
Correspondence to: Dr N Ijaz infection
([email protected]) From Borda and Wikramanayake (2015)

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 Clinical Skills for Postgraduate Examinations

is more prevalent in patients with lymphoma Figure 2. Severe seborrhoeic dermatitis of the scalp.
and organ transplant recipients (Borda and
Wikramanayake, 2015). The strongest
evidence comes from patients infected with
the human immunodeficiency virus (HIV)
who have developed acquired immune
deficiency syndrome (AIDS). Approximately
30–85% of patients with AIDS are affected
with seborrhoeic dermatitis (Amado et al,

©Dr P Marazzi/Science Photo Library

2013). While seborrhoeic dermatitis is not
an AIDS-defining illness per se, the British
HIV Association (2008) suggests offering
routine HIV tests to individuals with ‘severe
or recalcitrant seborrhoeic dermatitis’.

Neurological disease
Seborrhoeic dermatitis has an increased
prevalence in a number of neurological Figure 3. Erythematous papules of mild seborrhoeic dermatitis affecting the nasolabial fold.
and psychiatric conditions. Approximately
52–59% of patients with Parkinson’s
disease are affected by seborrhoeic
dermatitis (Arsenijevic et al, 2014). The
pathophysiology of this is complex,
including facial immobility contributing
to increased sebum accumulation. One
suggestion, however, is that patients with

©Dr P Marazzi/Science Photo Library

Parkinson’s disease have increased plasma
levels of α-melanocyte-stimulating hormone
(Arsenijevic et al, 2014). α-melanocyte-
stimulating hormone is responsible for
increasing sebum production and is under
the direct control of melanocyte-stimulating
hormone-inhibiting factor. In patients
with Parkinson’s disease, there is a lack of
melanocyte-stimulating hormone-inhibiting
factor because of inadequate dopamine Alternative factors Two types of seborrhoeic dermatitis can
levels. Therefore, patients with Parkinson’s Diet, in particular zinc deficiency, emotional appear on the chest, termed either petaloid or
disease are likely to have increased sebum stress and winter months are also implicated pityriasiform (National Institute for Health
levels and are more likely to develop in the development of seborrhoeic and Care Excellence, 2013).
seborrhoeic dermatitis. Furthermore, anti- dermatitis (National Institute for Health ■■ Petaloid: common, red-brown follicular
parkinsonian drugs such as L-dopa are and Care Excellence, 2013; Borda and and perifollicular papules with greasy
effective in reducing sebum secretion and Wikramanayake, 2015). scales. The papules can expand to form
treating the seborrhoeic dermatitis found in The presentation of seborrhoeic dermatitis patches resembling the shape of flower
these patients (Arsenijevic et al, 2014; Borda varies depending on the body site affected, age petals or medallions
and Wikramanayake, 2015). of the patient and skin colour. Seborrhoeic ■■ Pityriasiform: less common, thought to be
There also appears to be a link between dermatitis usually presents as symmetrical a more severe form of petaloid, presenting
neurological damage, for example traumatic erythematous greasy patches with yellowish as generalized macules and patches that
brain and spinal cord injury, and seborrhoeic scaling. There is a predilection for areas rich in resemble extensive pityriasis rosea.
dermatitis (Borda and Wikramanayake, sebaceous glands, namely the scalp (presenting Generalized seborrhoeic dermatitis is often
2015). It is speculated that this may be caused as dandruff; Figure 2), hairline, ears, eyebrows, found in immunocompromised patients and
by an accumulation of sebum and scale on eyelids (blepharitis), nasolabial folds (Figure can lead to the development of erythroderma
inadequately scrubbed skin. Furthermore, 3), upper lip, upper chest and back, umbilicus (erythema affecting >90% of body surface
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dysregulation of sympathetic outflow in and groin (National Institute for Health and area) (National Institute for Health and Care
areas below a spinal cord injury may lead to Care Excellence, 2013; Oakley, 2014; Borda Excellence, 2013; Borda and Wikramanayake,
an altered immune response and therefore and Wikramanayake, 2015). Pruritus is not 2015). Genital involvement can manifest
more favourable conditions for the growth uncommon, but is more often seen when the as scaly red plaques, which can present a
of Malassezia spp. (Han et al, 2015). scalp and ears are affected. diagnostic challenge particularly if it is the

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Core Training

only area affected. The differential diagnoses nuclei of keratinocytes) in the epidermis, Management
of balanitis, psoriasis or even Bowen’s disease plugged follicular ostia (the opening of hair The main goal of treatment is to reduce
should be considered in such cases (Salava, follicles) and spongiosis (oedema) (Clark et the psychological distress that seborrhoeic
2015). al, 2015). Parakeratosis is not exclusive to dermatitis may cause. Patients frequently
In infants, scalp disease or ‘cradle cap’ is seborrhoeic dermatitis and can also be found have concerns about the cosmetic effects
the most common clinical manifestation. in conditions such as psoriasis (one of the of the condition. Any concerns regarding
However, it can also spread to involve main differentials). It is therefore pertinent the psychological impact of the disease,
the face, armpit and groin folds. The rash that a thorough history and examination should be highlighted through the use of
consists of salmon pink patches which may should be performed. the Dermatology Life Quality Index (Araya
be associated with scaling and with little or When assessing a patient’s skin, the et al, 2015). Furthermore, it is important
no pruritus (Oakley, 2014). clinician should take into account the patient’s to mention that the condition is chronic,
age, gender, affected sites, distribution and and control rather than cure is the aim.
Differential and workup onset of lesions, past medical history (taking Treatment options include the use of
The diagnosis of seborrhoeic dermatitis is particular notice of any immunosuppressive antifungals, keratolytics, corticosteroids and
usually clinical and often does not require conditions), drug history, family history immunomodulators (Clark et al, 2015).
any formal investigation (Table 2). However, as well as everyday habits (Bukvic et al,
if the diagnosis is in doubt, a skin biopsy may 2012). The diagnosis can be challenging in Scalp and beard
be needed. Biopsy of seborrhoeic dermatitis individuals with darker skin, but the same Initially, mild seborrhoeic dermatitis of the
lesions show parakeratosis (retention of principles apply (Clark et al, 2015). scalp can be treated with over the counter
anti-dandruff shampoo containing selenium
sulfide, zinc pyrithione (e.g. Head and
Table 2. Differential diagnoses in seborrhoeic dermatitis per body site
Shoulders), or coal tar. Results improve if left
Scalp Psoriasis Sharply demarcated plaques. Thick, with a silvery scale. Features in for at least 5–10 minutes before rinsing.
such as pitting and onycholysis may aid the diagnosis Any thickening from scales can be removed
before shampooing by applying descaling
Sebopsoriasis Overlap between seborrhoeic dermatitis and psoriasis
preparations containing coconut oil and
Tinea capitis Leading edge (active border), scaly, red, slightly raised with a central salicylic acid (e.g. Neutrogena T/Gel, L’Oréal
clearing. There may be vesicles at the active border. Can lead to a Elvive, Selsun and Capasal shampoo).
scarring alopecia Over the long term, shampoos containing
Infected eczema Eczema which is weeping, crusted and can have pustules ketoconazole 2% (Nizoral) or ciclopirox 1%
(Loprox) can be used two or three times a
Systemic lupus Scarring alopecia with disc-like lesions week. This regimen should be followed for at
erythematosus
least 1 month after which it can be reduced
Face or retro- Systemic lupus Photosensitive, maculopapular eruption with fine scaling and a to once weekly (as a maintenance therapy)
auricle area erythematosus butterfly distribution with sparing of the nasolabial folds. Can be depending on symptom control. Severe
disc-like (discoid) scalp inflammation (Figure 2) can be treated
Rosacea Erythematous, eruptions of papules and pustules on forehead,
with potent topical corticosteroids such as
cheeks, nose, and eyes betamethasone valerate 0.1%, hydrocortisone
butyrate 0.1%, or mometasone furoate 0.1%
Impetigo Superficial skin infection caused by streptococci and/or (National Institute for Health and Care
staphylococci; begins as vesicles with thin, fragile roof Excellence, 2013; Oakley, 2014; Borda and
Lichen simplex Eczematous eruption caused by habitual scratching of single Wikramanayake, 2015; British Association
chronicus localized area; more common in adults, but possible in children of Dermatologists, 2015; Clark et al, 2015).
Upper chest Atopic Typically affects the antecubital and popliteal fossae. Associated with
Face and body
dermatitis pruritus and over time, lichenification through repeat scratching
Imidazole creams combined with low or
Pityriasis rosea Typically a herald patch or ‘mother patch’. Salmon pink plaques over mid-potency topical corticosteroids are first
the trunk and proximal extremities line. Examples of imidazole creams include
Pityriasis Flatter, extensive, less symmetrical than lesions of petaloid
ketoconazole 2%, clotrimazole 1%, econazole
versicolor seborrhoeic dermatitis. Often noticed after a holiday where the 1% and miconazole 2%. Creams are applied
person has been exposed to the sun twice or three times a day (depending on
the type of cream) and are used for a total of
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Psoriasis Numerous subtypes, including plaque, flexural, guttate and inverse. 4 weeks. Shampoos used for the scalp can also
Distinctive red, scaling round-to-oval plaques are common be used as a body wash alongside the creams.
Body folds Candidiasis Often found in the intertriginous regions Topical corticosteroids such as hydrocortisone
0.5%, hydrocortisone 1% or clobetasone
From National Institute for Health and Care Excellence (2013); Clark et al (2015)
butyrate 0.05% (Eumovate) can be used

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 Clinical Skills for Postgraduate Examinations

alone, but are more efficacious when used in focus on treatment of any underlying
combination with the creams. Intermittent immunocompromise (if any). This may KEY POINTS
use of steroids is preferable to continuous use, involve starting individuals on antiretrovirals, ■■ Seborrhoeic dermatitis is a common,
for the reasons stated previously. for example, if they are HIV positive. chronic, inflammatory skin disorder that
Combination creams containing both an Phototherapy, in particular narrow band can affect both adults and children.
antifungal and steroid are widely available ultraviolet B, improves symptoms in those ■■ The aetiology is multifactorial, but there
and examples include Daktacort, Lotriderm with severe seborrhoeic dermatitis. Usually is a strong correlation between the
and Trimovate (the latter is particularly 20–30 treatments are required for it to be presence of Malassezia yeasts and the
effective in seborrhoeic dermatitis in the beneficial. However, there are a number of development of seborrhoeic dermatitis.
groin). Particular care should be taken when disadvantages, including rapid disease relapse ■■ Clinical features may vary depending
treating patients with rosacea as steroids will and a theoretical risk of skin cancer (usually on the body site affected, age and skin
make this worse. In such cases, patients should seen between 250 and 300 treatments) colour. Commonly, there is a predilection
for areas rich in sebaceous glands.
be advised to carefully apply steroids to only (Bukvic et al, 2012). For these reasons it is
those areas affected by seborrhoeic dermatitis not a practical option. ■■ The main differential to exclude is
(National Institute for Health and Care Alternatively, oral antifungals such as psoriasis, but an overlap syndrome
termed ‘sebopsoriasis’ can be present.
Excellence, 2013; Oakley, 2014; Borda and itraconazole may be tried, but studies have
Wikramanayake, 2015; British Association not shown any significant therapeutic effect ■■ Treatment options include the use
of topical antifungals, keratolytics,
of Dermatologists, 2015; Clark et al, 2015). (Bukvic et al, 2012), so their use should be
corticosteroids and immunomodulators.
Blepharitis should be managed with balanced against their risk of hepatotoxicity
Maintenance therapy is often required.
good eye lid hygiene, avoiding eye makeup and the cost–benefit ratio. Both phototherapy
■■ Severe or widespread seborrhoeic
and contact lenses. A warm (but not hot) and systemic antifungal treatment can be
dermatitis may require the use of systemic
compress should be applied twice daily with used alongside topical agents.
agents or phototherapy, depending on
gentle wiping along eyelid margins to help clinician and patient preference.
clear debris. Conclusions
Topical calcineurin inhibitors such as Clinicians should attempt to make a prompt
tacrolimus 0.1% ointment (Protopic) and and accurate diagnosis in suspected cases get-file.ashx?id=180&itemtype=document
pimecrolimus 1% (Elidel) are alternative of seborrhoeic dermatitis. This should (accessed 21 May 2016)
second-line (off licence) agents which can be involve performing a thorough history British HIV Association (2008) UK National
Guidelines For HIV Testing. www.bhiva.org/
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agents work by inhibiting T lymphocyte- placed on the chronicity of the condition Tables1-2.pdf (accessed 21 May 2016)
driven cytokine production and consequently and therefore a control rather than a cure Bukvic ZM, Kralj M, Basta-Juzbasic A, Lakos Jukic
I (2012) Seborrhoeic dermatitis: An update. Acta
reducing cutaneous inflammation (Cook and approach is encouraged. Antifungal agents Dermatovenerol Croat 20(2): 98–104.
Warshaw, 2009). Randomized controlled and mild topical steroids are the cornerstones Clark GW, Pope SM, Jaboori KA (2015) Diagnosis
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Physician 91(3): 185–190.
equally as effective as topical corticosteroids preventing significant morbidity.  BJHM Cook BA, Warshaw EM (2009) Role of topical
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Conflict of interest: none. of seborrhoeic dermatitis: a review of
reduce steroid burden. There is debate about
pathophysiology, safety and efficacy. Am J
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