Approach

Symptom control is the mainstay of treatment. Topical agents such as corticosteroids, coal tar, calcineurin inhibitors, and antifungals are used for treatment.[19][20][21][22] Shampoos and scalp preparations are appropriate treatments when SD is confined to the scalp.[23] Systemic antifungals should be reserved for severe cases and avoided in infants and children.[24]

Scalp disease

Cradle cap in infants can usually be managed using emollients such as topical olive oil. Many of the studied treatments for cradle cap have low‐certainty evidence for comparisons and outcomes.[25] The first-line therapy for scalp SD in adults and children is a shampoo or scalp preparation containing one of the following compounds: salicylic acid, ketoconazole, selenium sulphide,crude coal tar, or pyrithione zinc.[26][27] Miconazole shampoo appears to be as effective as ketoconazole shampoo for scalp seborrhoeic dermatitis.[28] Topical corticosteroid preparations such as fluocinolone or hydrocortisone should be used as second-line treatment in children >2 years of age and in adults.[1]​ Shampooing with ciclopirox is considered a first-line treatment for scalp SD, particularly in Europe.[23][26] [ Cochrane Clinical Answers logo ]

Non-scalp disease

Topical corticosteroids or topical antifungals are often used in adults for SD affecting the face and body areas.[26] Low-potency topical corticosteroids are beneficial for adult SD of the flexural areas or for persistent recalcitrant SD in infants and children.

The appropriate potency of topical corticosteroid to use is determined by the severity and location of SD. Topical corticosteroids can cause skin atrophy, striae, hypopigmentation, and telangiectasia, so it is important to apply them sparingly and to use a low-potency preparation where possible. Topical corticosteroids are rated on a potency scale from 1 (highest potency) to 7 (lowest potency). High- to mid-potency corticosteroids (e.g., betamethasone) are used on thicker-skinned areas (e.g., the trunk and scalp) or for severe disease. Low-potency corticosteroids (e.g., desonide, hydrocortisone) should be used for mild disease or on areas with thinner skin (such as skin folds, neck, and face, or on infant skin), to avoid skin atrophy, telangiectasia, hypopigmentation, and striae.[29]

A topical azole antifungal, such as ketoconazole, may be combined with 2 weeks of daily topical corticosteroids for facial SD.[30] Ketoconazole can be used as a 2% cream or foam preparation.[31] Sertaconazole 2% cream is another choice for facial SD.[32] Provisional evidence exists for metronidazole gel being effective in the treatment of facial SD, with a similar reduction in severity scores compared with topical ketoconazole.[33]

Although topical calcineurin inhibitors are less effective than topical corticosteroids, and long-term use has been suggested as a possible cancer risk, they are used when there are concerns about skin atrophy.[34] In addition, tacrolimus 0.1% ointment may be of benefit used twice weekly to keep controlled facial SD in remission.[35]

Widespread or recalcitrant disease

Treatment with oral itraconazole or ketoconazole daily for 2 weeks is indicated for widespread or recalcitrant disease, although in general these should be avoided in infants and children.[8][24] Although oral antifungals are considered a last-line option in this selected patient group, their use remains controversial and is seldom necessary except in severe forms, such as explosive cases of SD seen in AIDS.[36] Systemic antifungals can rarely cause severe drug eruptions, including Stevens-Johnson syndrome and toxic epidermal necrosis. Ketoconazole may cause severe liver injury and adrenal insufficiency. In July 2013, the European Medicines Agency’s Committee on Medicinal Products for Human Use (CHMP) recommended that oral ketoconazole should not be used for the treatment of fungal infections, as the benefits of treatment no longer outweigh the risks. As a consequence of this, oral ketoconazole may be unavailable or restricted in some countries. This recommendation does not apply to topical formulations of ketoconazole.[37][38] The US Food and Drug Administration (FDA) recommend that oral ketoconazole should only be used for life-threatening fungal infections where alternative treatments are not available or tolerated, and when the potential benefits of treatment outweigh the risks. Its use is contraindicated in patients with liver disease. If used, liver and adrenal function should be monitored before and during treatment.[39]

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