Seborrheic dermatitis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [2]; Aysha Aslam, M.B.B.S[3]

Synonyms and keywords: Seborrheic eczema; Seborrhea; Cradle cap

Overview

Seborrheic eczema (also known as Seborrheic dermatitis, seborrhea) is a skin disorder affecting the scalp, face, and trunk. Seborrheic dermatitis causes flaky, itchy, red skin and temporary hair loss. It particularly affects the sebum-gland rich areas of skin. Causes of seborrheic dermatitis include Malassezia furfur (formerly known as Pityrosporum ovale) as well as genetic, environmental, hormonal, and immune-related factors. Medical therapy for seborrheic dermatitis includes antifungal agents, corticosteroids, and lithium salts.

Historical Perspective

Classification

There is no established classification system for seborrheic dermatitis. However, it may be classified according to the anatomical location, age group, symptoms, etiology and severity.[3][4][5][6][7]

Classification by Anatomy

Seborrheic dermatitis may be classified on the basis of anatomical location into following types:[8][3][9][10]

  • Localized
    • Scalp: Most common presentation in infants known as cradle cap
    • Face: Most commonly involves eyelids, eyebrows, and nasolabial folds
    • Retroauricular
    • Body folds: Commonly affects axilla, breast folds, and inguinal area
    • Trunk: May be seen in severe cases and most common site of involvement is lower abdomen
    • Upper Chest: Most commonly seen in adults
      • Pityriasiform: Oval macules and patches.
      • Petaloid type: Small papules with oily scales may enlarge to become patches resembling petals of flower.
  • Generalized: Mostly seen in infants; it is associated with Leiner's disease and children with severe immunodeficiency.[11]

Classification by Age

  • Infantile: Occurs in first three months of life.
  • Adults: Occurs most commonly between 30-60 years of age.

Classification by Symptomatic Presentation

  • Non pruritic: Most commonly occurs in infants
  • Pruritic: Most commonly occurs in older children and adults

Classification by Etiology

Classification by Severity

Pathophysiology

The exact pathophysiology of seborrheic dermatitis remains unclear. However, several mechanisms are hypothesized to play a role in pathogenesis of seborrheic dermatitis.[12] [13][14][15][11]

Pathogenesis

Hypotheses regarding the pathogenesis of seborrheic dermatitis include:

Hypotheses related to Malassezia :

  • A strong correlation between presence of the fungal yeast Malassezia and response to antifungals in patients with seborrheic dermatitis.[16]

Other Hypotheses

Sebum gland activity may correlate with seborrheic dermatitis.[15][20]
Elevated levels of HLA-AW30, HLA-AW31, HLA-A32, HLA-B12 and HLA-B18 and increased levels of total serum IgA and IgG antibodies have been detected in seborrheic dermatitis patients. This implies an immune mediated pathological mechanism.[14][21][22]
  • Epidermal barrier dysfunction
Abnormalities in stratum corneum that may be associated with seborrheic dermatitis include:
  • Corneocyte shape
  • Corneodesmosomes
  • Disrupted lipid lamellar structure [23]
  • Neurogenic and other factors
Patients with parkinsonism may have increase levels of α-melanocyte stimulating hormone (α-MSH) levels and seborrheic dermatitis in these patients respond to L-dopa treatment[22]

Genetics

There is no specific genetic cause for seborrheic dermatitis.[24].[25]

Associated conditions

Gross Pathology

Superficial flaking and redness are characteristic findings of seborrheic dermatitis.[26]

Microscopic Histopathology

Histopathological findings of seborrheic dermatitis may be categorized into the following stages: [21][28]

  • Acute
  • Subacute
  • Chronic
  • Extensive psoriasiform hyperplasia
  • Minimal spongiosis
  • Follicular crusting

Causes

The cause of seborrheic dermatitis remains unknown; however, the following factors may have been implicated:

Differentiating Seborrheic dermatitis from Other Diseases

Symptoms of seborrheic dermatitis may overlap with other skin conditions such as psoriasis, candidiasis, contact dermatitis, and atopic dermatitis. Differential diagnosis of seborrheic dermatitis may be classified into two types by age group:[37][38][39][17][40][41][28]

Differential diagnosis in Infants

Disease Rash Characteristics Signs and Symptoms Associated Conditions Images
Cutaneous T cell lymphoma/Mycosis fungoides[42]
By Bobjgalindo - Own work, GFDL, https://commons.wikimedia.org/w/index.php?curid=7139812
Pityriasis rosea[43]
  • Pink or salmon in color, which may be scaly; referred to as "herald patch"
  • Oval shape
  • Long axis oriented along the cleavage lines
  • Distributed on the trunk and proximal extremities
  • Squamous marginal collarette and a “fir-tree” or “Christmas tree” distribution on posterior trunk
  • Secondary to viral infections
  • Resolves spontaneously after 6-8 weeks
By James Heilman,MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=16305230
Pityriasis lichenoides chronica
  • Recurrent lesions are usually less evenly scattered than in cases of psoriasis
  • Brownish red or orange-brown in color
  • Lesions are capped by a single detachable, opaque, mica-like scale
  • Often leave hypopigmented macules
Nummular dermatitis[46]
  • Lesions commonly relapse after occasional remission or may persist for long periods
  • Pruritus
Secondary syphilis[47]
  • Round, coppery, red colored lesions on palms and soles
  • Papules with collarette of scales
By James Heilman,MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=16305230
Bowen’s disease[48]
  • Erythematous, small, scaly plaque, which enlarges erratically over time
  • Scale is usually yellow or white and it is easily detachable without any bleeding
  • Well-defined margins
By Klaus D. Peter, Gummersbach, Germany - Own work (own photograph), CC BY 3.0 de, https://commons.wikimedia.org/w/index.php?curid=6839115
Exanthematous pustulosis[50]
By See below - (2010). "Acute generalized exanthematous pustulosis: an unusual side effect of meropenem". Indian J Dermatol 55 (2): 176–7. DOI:10.4103/0019-5154.62759. PMID 20606889. PMC: 2887524., CC BY 1.0, https://commons.wikimedia.org/w/index.php?curid=52979729
Hypertrophic lichen planus[52]
Di James Heilman, MD - Opera propria, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=11509003
Sneddon–Wilkinson disease[54]
  • Flaccid pustules that are often generalized and have a tendency to involve the flexural areas
  • Annular configuration
Small plaque parapsoriasis[58]
  • Erythematous plaques with fine scaly surface
  • May present with elongated, finger-like patches
  • Symmetrical distribution on the flanks
  • Known as digitate dermatosis
  • Lesions may be asymptomatic
  • May be mildly pruritic
  • May fade or disappear after sun exposure during the summer season, but typically recur during the winter
Intertrigo[60]
Source: https://www.cdc.gov/
Langerhans cell histiocytosis[61]
  • Scaling and crusting of scalp
Tinea manuum/pedum/capitis[65]
  • Scaling, flaking, and sometimes blistering of the affected areas
  • Hair loss with a black dot on scalp in case of tinea capitis
Seborrheic dermatitis
By Roymishali - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=27267929

Differential diagnosis in Adults

Epidemiology and Demographics

Epidemiology

Worldwide, the prevalence of seborrheic dermatitis is estimated to be 11000 cases per 100,000.[24] Prevalence of seborrheic varies among individuals based on the following factors:

  • Higher reporting of mild cases
  • Higher in patients with HIV with 35000 per 100,000 in early diagnosis and 85000 per 100,000 with full blown AIDS[67]
  • Higher prevalence seen among those directly exposed to UV radiation[68]

Demographics

Age

Seborrheic dermatitis demonstrates a tri-modal age distribution as follows:[71][72][21]

  • The first incidence peak is seen in infants around three to four months of age, which usually resolves within 12 months
  • The second incidence peak is seen around puberty.
  • The third incidence peak is seen after age 50 with the highest prevalence seen among ages 33-44 years.[73]
  • Age groups showing lowest prevalence of clinical disease is seen in individuals younger than 12 years.[74]

Gender

Males are more commonly affected with seborrheic dermatitis than females.[75]

Race

  • Seborrheic dermatitis is rarely seen in African Americans.
  • If seborrheic dermatitis is seen in this population, it leads to high suspicion of HIV in affected individuals.[76]

Risk Factors

The most common risk factors for seborrheic dermatitis include:[77][17]

Immunosuppression

Neurologic and psychiatric cases

Genetic disorders

Other risk factors

Screening

There are no screening guidelines for seborrheic dermatitis.[84]

Natural History, Complications, and Prognosis

Natural History

  • The symptoms of seborrheic dermatitis usually develop in the first three months in infants. It may resolve without treatment in most cases in few months and rarely presents after 12 months.[85]
  • In adults, symptoms of seborrheic dermatitis usually develop in the second and third decade of life, and start with symptoms such as redness, scaling and crusting on affected areas. However, occurrence of seborrheic dermatitis is highly variable and it may present after 50 years of age.
  • The course of disease is highly variable among individuals despite treatment. Some cases present with more frequent relapses than others.[71]

Complications

Common complications of seborrheic dermatitis include:[86][71][87][88][89][11]

Prognosis

  • The prognosis of seborrheic dermatitis is excellent in infants; it is a self limited disease and usually resolves within few months after birth.
  • In adults, it is a recurrent condition with no permanent cure.[90][91]

Diagnosis

There is no definitive diagnostic criteria for seborrheic dermatitis. Diagnosis of seborrheic dermatitis is primarily clinical; it is based on history and physical examination findings.[92]

History

Obtaining complete history is important in making diagnosis of seborrheic dermatitis as it will give an insight into cause and associated risk factors for the disease. In addition to symptoms of seborrheic dermatitis, patients may present with symptoms of one of the following associated conditions:[93][94][95][17] [96][97][98]

Symptoms

Symptoms of seborrheic dermatitis may be categorized according to age as follows:[24][99]

Infants

Infants usually present in the first few months of life. Symptoms can be divided into following types depending on extent of involvement.

  • Localized
    • Redness and flaking
    • Pruritis
    • Most common sites involved are scalp and face
    • Other sites involved include retroauricular area, nasolabial folds, cheeks, eyebrows and eyelids
    • Napkin or diaper area involvement
  • Generalized
    • Few cases may present with generalized involvement such as lower abdomen, groin and pubic area.

Adults

The most common symptoms of seborrheic dermatitis may be divided into two types based on extent of involvement:[24]

  • Localized
    • Macules, thin plaques, or red patches(scalp, face, nasolabial folds, anterior hairline, eyebrows, glabella region of the forehead, melolabial folds, ears, central chest, and genital region)
    • Pruritis
    • Fine scaling (mild cases)
    • Redness and yellow to white crusting or scaling (severe disease)
    • Redness, itching and yellow crusting of eye lashes (Blepharitis).
    • Repeated itching of ear causing secondary bacterial infection resulting in fever and ear pain.

Physical Examination

Physical examination may be divided into two types according to age group:

Age Site involved Local Examination Image[102]
Infants General Appearance Infants often looks healthy with a good appetite and sleep habits.
Scalp Fine scaling in mild cases. Thick greasy scales with erythema in severe cases.[103]
Face Face may present with scaly salmon colored scales.
Neck, Axillae and Body Folds Non-scaly moist glistening appearance of lesions which tend to appear confluent.[17]
Trunk Trunk involvement is seen in severe cases. However, the diaper area iscommonly involved which presents with erythema and maceration of skin with edema of surrounding skin. Secondary bacterial and candidal infections are common in these cases.[104]
Generalized Most commonly seen in Leiner's disease, which is an immunosuppressive condition. It may involve unusual sites such as extremities and trunk with scaling and erythematous patches. Scaling and crusting usually spreads to involve other parts of the body with extensive peeling of skin.[105][106][107]
Adults General appearance Adults may present with a healthy general appearance in mild cases or may present in considerable distress due to widespread involvement especially. Patients may appear ill in cases with underlying diseases associated with seborrheic dermatitis such as HIV, malignancy, or parkinsonism.[78]
Scalp Mild desquamation to honey coloured crusting of the scalp causing alopecia.
Face/Retroauricular

areas

May present as a "butterfly rash". Malar erythema and scaling in a symmetrical pattern . Yellowish scaling between eyelashes and eyelids causing blepharitis with honey colored crusting on free margins.[71]
Upper Chest SD presents as petalloid or pityriasiform.

Petalloid: Small reddish follicular or perifollicular papules that may coalesce forming patches resembling petals of flower.
Pityriasiform: Common on skin tension lines and intertriginous areas and presents as oval scaly macules and patches. This type involves extensive involvement of the body.[100]

Body Folds Lesions usually present as moist, macerated, and erythematous lesions. May lead to fissuring and secondary infection.[17]
SD of

Immunosuppression

It may present as extensive scaling and erythema involving unusual sites such as extremities and is refractory to treatment. It is usually seen in children and adults with immunosuppression such as HIV/AIDS.[108][109]


Imaging Findings

There are no imaging findings associated with seborrheic dermatitis.[41]

Other Diagnostic Studies

There are no other diagnostic studies for seborrheic dermatitis.

Treatment

The mainstay of treatment for seborrheic dermatitis is medical therapy. Depending on age and severity of symptoms the treatment may be categorized as follows:

Severity Acute Therapy Maintainence Therapy
Infants Mild
  • Self limited, resolves in few months
Moderate to Severe
Adults Mild
Moderate to Severe

The following are the preferred treatment regimens for seborrheic dermatitis:[128]

  • Preferred regimen (1): Ketoconazole 2% in shampoo, foam, gel, or cream
  • Scalp: Twice/week for clearance THEN once/week or every other week for maintenance
  • Other areas: From bid to twice/week for clearance THEN from twice/week to once every other week for maintenance
  • Preferred regimen (2): Bifonazole 1% in shampoo or cream
  • Scalp: 3 times/week for clearance
  • Other areas: qd for clearance
  • Preferred regimen (3): Ciclopirox olamine (also called ciclopirox) 1.0% or 1.5% in shampoo or cream
  • Scalp: Twice to 3 times/week for clearance THEN once/week or every 2 week for maintenance
  • Other areas: Twice daily for clearance THEN qd for maintenance
  • Scalp: Twice weekly in a short- contact fashion (up to 10 min application, then washing)
  • Preferred regimen (5): Desonide 0.05% lotion bid on scalp and other areas

Plant-based treatments

Main article: Phytotherapy

The World Health Organization mentions Aloe vera gel as a yet to be scientifically proven traditional medicine treatment for Seborrhoeic dermatitis.[129]

Surgery

Surgical intervention is not recommended for the management of seborrrheic dermatitis.

Prevention

Primary Prevention

There is no established method for prevention of seborrheic dermatitis.[71]

Secondary Prevention

Secondary prevention strategies following seborrheic dermatitis include:

References

  1. ↑ Shuster S (1984). "The aetiology of dandruff and the mode of action of therapeutic agents". Br J Dermatol. 111 (2): 235–42. PMID 6235835.
  2. ↑ Low, R. Cranston, and H. W. Barber. "Discussion on the etiology of seborrhoea and seborrhoeic dermatitis." The British Medical Journal (1922): 752-757.
  3. ↑ 3.0 3.1 Dessinioti C, Katsambas A (2013). "Seborrheic dermatitis: etiology, risk factors, and treatments: facts and controversies". Clin Dermatol. 31 (4): 343–51. doi:10.1016/j.clindermatol.2013.01.001. PMID 23806151.
  4. ↑ Dessinioti, Clio, and Andreas Katsambas. "Seborrheic dermatitis: Etiology, risk factors, and treatments:: Facts and controversies." Clinics in dermatology 31.4 (2013): 343-351.
  5. ↑ ===Classification by Anatomical Location===Peyri, J., and M. Lleonart. "Clinical and therapeutic profile and quality of life of patients with seborrheic dermatitis." Actas Dermo-Sifiliográficas (English Edition) 98.7 (2007): 476-482.
  6. ↑ name="pmid6220754">Burton JL, Pye RJ (1983). "Seborrhoea is not a feature of seborrhoeic dermatitis". Br Med J (Clin Res Ed). 286 (6372): 1169–70. PMC 1547390. PMID 6220754.
  7. ↑ 7.0 7.1 {{cite journal| author=Thomas DS, Ingham E, Bojar RA, Holland KT| title=In vitro modulation of human keratinocyte pro- and anti-inflammatory cytokine production by the capsule of Malassezia species. | journal=FEMS Immunol Med Microbiol | year= 2008 | volume= 54 | issue= 2 | pages= 203-14 | pmid=: 18752620 | doi=10.1111/j.1574-695X.2008.00468.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?
  8. ↑ 8.0 8.1 Schwartz RA, Janusz CA, Janniger CK (2006). "Seborrheic dermatitis: an overview". Am Fam Physician. 74 (1): 125–30. PMID 16848386.
  9. ↑ Dessinioti, Clio, and Andreas Katsambas. "Seborrheic dermatitis: Etiology, risk factors, and treatments:: Facts and controversies." Clinics in dermatology 31.4 (2013): 343-351.
  10. ↑ ===Classification by Anatomical Location===Peyri, J., and M. Lleonart. "Clinical and therapeutic profile and quality of life of patients with seborrheic dermatitis." Actas Dermo-Sifiliográficas (English Edition) 98.7 (2007): 476-482.
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  12. ↑ name="pmid6220754">Burton JL, Pye RJ (1983). "Seborrhoea is not a feature of seborrhoeic dermatitis". Br Med J (Clin Res Ed). 286 (6372): 1169–70. PMC 1547390. PMID 6220754.
  13. ↑ 13.0 13.1 Tajima M (2001). "Seborrhoeic dermatitis and Pityrosporum (Malassezia) folliculitis: characterization of inflammatory cells and mediators in the skin by immunohistochemistry". Br J Dermatol. 144 (3): 549–56. PMID 11260013.
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  20. ↑ Warner, Ronald R., et al. "Dandruff has an altered stratum corneum ultrastructure that is improved with zinc pyrithione shampoo." Journal of the American Academy of Dermatology 45.6 (2001): 897-903.
  21. ↑ "Dermatology Atlas".
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  29. ↑ 35.0 35.1 35.2 "Seborrheic Dermatitis: An Overview - July 1, 2006 -- American Family Physician". www.aafp.org. Retrieved 2008-03-19.
  30. ↑ "eMedicine - Nutritional Neuropathy : Article by R Andrew Sewell". www.emedicine.com. Retrieved 2008-03-19.
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  34. ↑ Schwartz, Robert A., Christopher A. Janusz, and Camila K. Janniger. "Seborrheic dermatitis: an overview." Am Fam Physician 74.1 (2006): 125-130.
  35. ↑ 41.0 41.1 Clark GW, Pope SM, Jaboori KA (2015). "Diagnosis and treatment of seborrheic dermatitis". Am Fam Physician. 91 (3): 185–90. PMID 25822272.
  36. ↑ "Mycosis Fungoides and the Sézary Syndrome Treatment (PDQ®)—Patient Version - National Cancer Institute".
  37. ↑ Mahajan K, Relhan V, Relhan AK, Garg VK (2016). "Pityriasis Rosea: An Update on Etiopathogenesis and Management of Difficult Aspects". Indian J Dermatol. 61 (4): 375–84. doi:10.4103/0019-5154.185699. PMC 4966395. PMID 27512182.
  38. ↑ Prantsidis A, Rigopoulos D, Papatheodorou G, Menounos P, Gregoriou S, Alexiou-Mousatou I, Katsambas A (2009). "Detection of human herpesvirus 8 in the skin of patients with pityriasis rosea". Acta Derm. Venereol. 89 (6): 604–6. doi:10.2340/00015555-0703. PMID 19997691.
  39. ↑ Smith KJ, Nelson A, Skelton H, Yeager J, Wagner KF (1997). "Pityriasis lichenoides et varioliformis acuta in HIV-1+ patients: a marker of early stage disease. The Military Medical Consortium for the Advancement of Retroviral Research (MMCARR)". Int. J. Dermatol. 36 (2): 104–9. PMID 9109005.
  40. ↑ Jiamton S, Tangjaturonrusamee C, Kulthanan K (2013). "Clinical features and aggravating factors in nummular eczema in Thais". Asian Pac. J. Allergy Immunol. 31 (1): 36–42. PMID 23517392.
  41. ↑ "STD Facts - Syphilis".
  42. ↑ Neagu TP, Ţigliş M, Botezatu D, Enache V, Cobilinschi CO, Vâlcea-Precup MS, GrinŢescu IM (2017). "Clinical, histological and therapeutic features of Bowen's disease". Rom J Morphol Embryol. 58 (1): 33–40. PMID 28523295.
  43. ↑ Murao K, Yoshioka R, Kubo Y (2014). "Human papillomavirus infection in Bowen disease: negative p53 expression, not p16(INK4a) overexpression, is correlated with human papillomavirus-associated Bowen disease". J. Dermatol. 41 (10): 878–84. doi:10.1111/1346-8138.12613. PMID 25201325.
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