Therapeutic Update on Seborrheic Dermatitis

I. Stefanaki, MD; A. Katsambas, MD


Skin Therapy Letter. 2010;15(5):1-4. 

In This Article

Topical Therapies

Topical therapies are the mainstay of treatment as the condition is recurrent, usually mild, and responds well to these agents.


Since the first publication in 1984 on the use of ketoconazole in seborrheic dermatitis,[7] several studies have validated its efficacy utilizing various vehicles of delivery (e.g., cream, foam, gel, and shampoo).[8–10] Ketoconazole shampoo 2% is superior to 1%[11] and can be used once-weekly as maintenance therapy for scalp seborrheic dermatitis.[10]

Another topical azole, bifonazole 1% cream, is likewise effective and provides the additional advantage of once-daily application. It has also been tried successfully in combination with 40% urea for scalp seborrheic dermatitis.[12] Bifonazole shampoo used 3 times weekly was significantly more beneficial than placebo in a randomized, double-blind study of 44 patients.[13] Miconazole can also be used either alone or in combination with hydrocortisone.[14]

Ciclopirox has both antifungal and anti-inflammatory properties.[15] Ciclopirox 1% cream is superior to placebo for facial seborrheic dermatitis.[16] The response rates appear to be dose-dependent, with higher concentrations (1% vs. 0.1% or 0.3%) and more frequent use yielding better results.[17,19] Combinations of ciclopirox 1.5% shampoo with salicylic acid 3% or zinc pyrithione 1% are also effective.[19,20] Statistical non-inferiority of ciclopirox in comparison with ketoconazole has been demonstrated.[21]


For severe seborrheic dermatitis, low- or medium-potency topical corticosteroids can be used when beginning treatment, either alone or in combination with an antifungal agent, to limit inflammation. Prolonged and/or frequent use should be avoided due to their well known associated risks (e.g., atrophy, telangiectasias, hypertrichosis, and perioral dermatitis). In a double-blind controlled study, 70 seborrheic dermatitis patients were treated with either miconazole 2% and hydrocortisone 1% in combination, miconazole 2%, or 1% hydrocortisone. Patients in both miconazole- containing treatment arms showed significant improvement when compared with those who received hydrocortisone 1% cream as prophylactic therapy.[14] Miconazole treatments also lowered the number of Malassezia spp. yeasts.[14] Double- blind comparative studies have found that hydrocortisone cream is not superior to ketoconazole 2% cream in improving seborrheic dermatitis symptoms, as significantly higher reductions in the number of Malassezia spp. were observed with ketoconazole, when compared with hydrocortisone.[22] Ketoconazole 2% foaming gel was found to be superior to betamethasone dipropionate 0.05% lotion in reducing symptoms and lowering the number of Malassezia spp.[23]

Zinc Pyrithione

Zinc pyrithione 1% shampoo in comparison with ketoconazole 2% shampoo has produced inferior results, whereas selenium sulphide exhibited similar efficacy.[24,25]


Topical metronidazole 0.75% gel for seborrheic dermatitis has been evaluated in only a limited number of double-blind studies with contradictory results. In two trials, metronidazole showed greater efficacy over placebo26 and was equally effective as ketoconazole 2% cream,[27] while in two other studies it was not superior to placebo.[28,29]

Lithium Salts

Both lithium succinate and lithium gluconate have demonstrated effectiveness in treating seborrheic dermatitis, probably due to their anti-inflammatory effects. Lithium succinate 8% ointment was investigated twice-daily (for a total of 8 weeks) and showed significantly greater efficacy than placebo.[30] It has also been used successfully in HIV patients with facial seborrheic dermatitis.[31] Lithium gluconate 8% ointment used twice-daily was tested in a multicenter, randomized, double-blind, placebo-controlled clinical trial in 129 patients.[32] After 8 weeks, 29.1% in the lithium group and 3.8% in the placebo group had experienced complete remission. Lithium gluconate 8% ointment used twice-daily was 22% more effective than ketoconazole 2% emulsion used twice-weekly in a randomized study of 288 patients.[33]

Calcineurin Inhibitors

In a randomized, double-blind, vehicle-controlled 4-week efficacy trial of twice-daily pimecrolimus 1% cream in 96 patients, topical calcineurin inhibitor (TCI) therapy was effective and well tolerated for the treatment of facial seborrheic dermatitis.[34] In two randomized clinical trials,[35,36] pimecrolimus 1% proved to be equally effective as topical corticosteroids (hydrocortisone acetate 1% cream or betamethasone 17-valerate 0.1% cream). Furthermore, pimecrolimus demonstrated additional benefits, such as longer periods of remission and milder relapses, when compared with betamethasone.[35] This TCI has also been tested against ketoconazole 2% cream in an open randomized study that showed comparable efficacy, but more frequent side-effects were reported with pimecrolimus treatment.[37] Topical tacrolimus 0.1% ointment was tried in an open-label 4-week randomized study against betamethasone 17-valerate lotion and zinc pyrithione 1% shampoo in 83 patients with seborrheic dermatitis of the scalp.[38] Tacrolimus ointment demonstrated greater prolonged efficacy than topical steroids, but exhibited shorter durability of improvement than zinc pyrithione shampoo. Due to the increased viscosity of the tacrolimus ointment, treatment was inconvenient to use on the scalp.

Coal Tar Shampoos

The beneficial effects of tar in seborrheic dermatitis may be attributed to its anti-proliferative and anti-inflammatory properties, antifungal action, and inhibition of sebum secretion.[39] In a randomized, double-blind parallel-group trial, treatment with 4% coal tar shampoo resulted in a significantly greater reduction in scalp seborrheic dermatitis, when compared with placebo, and the result was further enhanced when coal tar was combined with ciclopirox olamine.[40]

Selenium Sulphide

In a randomized double-blind trial, selenium sulfide 2.5% was tested against ketoconazole 2% and placebo in 246 patients with moderate to severe dandruff.[41] Both ketoconazole and selenium sulfide shampoos were effective, but ketoconazole was better tolerated.

Other Topical Treatments

There are scarce reports of successful treatment with benzoyl peroxide,42 azelaic acid,43 1a-24 (R)-dihydroxycholecalciferol (tacalcitol) cream,[44] and MAS064D cream (a non-steroidal preparation containing multiple active ingredients that include emollients, anti-inflammatories, keratolytics, and an antimycotic).[45]


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