Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

cradle cap in infants

1st line – emollients

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ACUTE
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cradle cap in infants
1st line – 

emollients

Cradle cap in infants can usually be managed using emollients such as topical olive oil applied once or twice a day as needed. Many of the studied treatments for cradle cap have low‐certainty evidence for comparisons and outcomes.[25]

Primary options

olive oil topical: apply once or twice daily to the affected area(s) when required

2nd line – topical corticosteroids

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ACUTE
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cradle cap in infants
2nd line – 

topical corticosteroids

Consider SD to be recalcitrant if treatment is required beyond 3 months. Particular caution should be used in infants, where use of a low-potency topical corticosteroid should be reserved for severe, recalcitrant cases. If the infant is unresponsive to topical hydrocortisone, referral to a dermatologist is indicated.

Primary options

hydrocortisone topical: (0.25% lotion) apply to scalp once or twice daily

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limited to scalp in children and adults

1st line – topical shampoos

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ACUTE
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limited to scalp in children and adults
1st line – 

topical shampoos

The first-line therapy for scalp SD is a shampoo or scalp preparation containing one of the following compounds: salicylic acid, ketoconazole,selenium sulfide, crude coal tar, or pyrithione zinc.[26][27] Miconazole shampoo appears to be as effective as ketoconazole shampoo for scalp seborrheic dermatitis.[28] Shampooing with ciclopirox is considered a first-line treatment for scalp SD, particularly in Europe.[23][26] [ Cochrane Clinical Answers logo ]

Pyrithione zinc has bacteriostatic and fungistatic properties and is a component of many proprietary shampoos.

Salicylic acid has keratolytic properties and is used in SD where scaling and hyperkeratosis are prominent.

Coal tars are antipruritic, have mild antiseptic function, and reduce the thickness of the epidermis.[38] Stronger preparations may be used in adults and resistant cases in children. A 10% coal tar solution (LCD) can be used either as target scalp therapy or as a shampoo. Some preparations include paraffin, which acts as an emollient. Tars can cause irritation and should not be used on face, skin flexures, or genitalia.

Treatment course is generally 2-4 weeks. Consider SD to be recalcitrant if treatment is required beyond 3 months.

Primary options

pyrithione zinc topical: (1% shampoo) apply to scalp twice weekly

OR

coal tar topical: (1% solution) apply to scalp twice weekly

OR

coal tar topical: (10% solution) apply to affected areas of scalp for 5-60 minutes (gel) three times weekly, then lather and rinse thoroughly; or apply three times weekly (shampoo), lather into wet hair for 3-5 minutes, rinse and repeat application

OR

salicylic acid topical: (2-6% shampoo) apply to scalp twice weekly

OR

selenium sulfide topical: (1% shampoo) apply to scalp twice weekly

OR

ciclopirox topical: (1% shampoo) apply to scalp twice weekly

OR

ketoconazole topical: (2% shampoo) apply to scalp twice weekly

OR

miconazole topical: (2% shampoo) apply to scalp twice weekly

2nd line – topical corticosteroids

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ACUTE
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limited to scalp in children and adults
2nd line – 

topical corticosteroids

Topical corticosteroid preparations such as fluocinolone or hydrocortisone should be used as second-line treatment in children ages >2 years and adults.[1]

Skin atrophy, striae, hypopigmentation, and telangiectasia may occur after long-term use with potent topical corticosteroids; they should be used for short durations to minimize potential adverse effects.

Consider SD to be recalcitrant if treatment is required beyond 3 months.

Primary options

hydrocortisone topical: (0.1% lotion) apply to scalp two to three times daily

OR

fluocinolone topical: (0.01% solution) apply to scalp once or twice daily

limited to nonscalp area in children and adults

1st line – topical corticosteroids and/or antifungals

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ACUTE
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limited to nonscalp area in children and adults
1st line – 

topical corticosteroids and/or antifungals

Topical corticosteroids are often used in adults for SD affecting the face and body areas. Low-potency creams should be used on the face and intertriginous areas in adults.

Low-potency topical corticosteroids should be used for persistent recalcitrant SD in infants and children.

Skin atrophy may occur after long-term use with potent topical corticosteroids. The potency of topical corticosteroid to be used is determined by the severity and location of the SD.

Topical corticosteroids are rated on a potency scale from 1 (highest potency) to 7 (lowest potency).

High- to mid-potency corticosteroids (e.g., betamethasone) can be used on thicker-skinned areas such as the trunk and scalp.

Low-potency corticosteroids (e.g., desonide, hydrocortisone) should be used on areas with thinner skin (such as skin folds, neck, and face), to avoid skin atrophy, telangiectasia, hypopigmentation, and striae.[29]

Topical antifungal agents target theMalassezia species associated with SD. The main preparation used is the topical azole antifungal ketoconazole, which has anti-inflammatory activity. [ Cochrane Clinical Answers logo ] Sertaconazole cream is another choice for facial SD.[32]

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]

If there is not a satisfactory response to therapy within 3 months, then one should move onto the next line of treatment with topical calcineurin inhibitors.

Primary options

desonide topical: (0.05%) apply sparingly to the affected area(s) twice daily

OR

hydrocortisone topical: (2.5%) apply sparingly to the affected area(s) twice daily

OR

betamethasone dipropionate topical: (0.05%) apply sparingly to the affected area(s) twice daily

OR

ketoconazole topical: (2%) apply to the affected area(s) twice daily for 2-4 weeks

OR

sertaconazole topical: (2%) apply to the affected area(s) twice daily for 2-4 weeks

Secondary options

ketoconazole topical: (2%) apply to the affected area(s) twice daily for 2-4 weeks

-- AND --

desonide topical: (0.05%) apply sparingly to the affected area(s) twice daily

or

hydrocortisone topical: (2.5%) apply sparingly to the affected area(s) twice daily

or

betamethasone dipropionate topical: (0.05%) apply sparingly to the affected area(s) twice daily

2nd line – topical calcineurin inhibitors

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ACUTE
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limited to nonscalp area in children and adults
2nd line – 

topical calcineurin inhibitors

Pimecrolimus cream is an effective and well-tolerated treatment for moderate to severe facial SD.[19][34][39][40] Because of black box warnings concerning malignancy, it is confined to a second-line therapy for mild to moderate disease when other topical treatments fail or are not indicated. Tacrolimus has similar use in SD.[20][41] Intermittent use of tacrolimus (twice weekly) may be of benefit to keep controlled facial SD in remission.[35]

Both treatments are useful in thin-skinned areas, where application of an equivalent potent topical corticosteroid may lead to skin atrophy, telangiectasia, hypopigmentation, and striae.[29]

Prolonged use should be avoided as this may aggravate superficial bacterial, fungal, or viral infections.

Consider monitoring for localized lymphadenopathy and acute localized reactions including pruritus or burning during the first 1-3 days of use.

Consider SD to be recalcitrant if there is not a satisfactory response within 3 months.

Primary options

pimecrolimus topical: (1%) apply sparingly to the affected area(s) once or twice daily

OR

tacrolimus topical: (0.1%) apply sparingly to the affected area(s) once daily; can be used twice weekly to keep in remission

widespread or recalcitrant disease in adults

1st line – oral antifungal therapy

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ACUTE
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widespread or recalcitrant disease in adults
1st line – 

oral antifungal therapy

Systemic antifungals should be reserved for particularly severe and/or recalcitrant forms of SD and in general should be avoided in infants and children.[24]

Ketoconazole may cause severe liver injury and adrenal insufficiency. In July 2013, the US Food and Drug Administration (FDA) recommended 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.[37]

Duration of therapy should not exceed 2 weeks and extreme care should be exercised in immunocompromised patients.

Primary options

itraconazole: 100-400 mg/day orally given in 2 divided doses if dose >200 mg/day

Secondary options

ketoconazole: 200-400 mg orally once daily

widespread or recalcitrant disease in children

1st line – dermatology referral

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widespread or recalcitrant disease in children
1st line – 

dermatology referral

Widespread recalcitrant SD in children should be managed by a specialist dermatologist.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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