脂漏性皮膚炎治療 from uptodate Seborrheic dermatitis in adolescents and adults
外用抗真菌藥物（例如酮康唑、其他唑類、環吡酮胺）在治療頭皮和臉部脂漏性皮膚炎方面已得到很好的應用。它們減少受影響皮膚上糠秕馬拉色菌數量的能力及其抗炎特性[28,29]。局部抗發炎藥物（例如局部皮質類固醇、局部鈣調神經磷酸酶抑制劑）也常單獨或與局部抗真菌藥物聯合用於治療脂漏性皮膚炎。
治療目標 — 脂漏性皮膚炎是一種慢性疾病。治療的主要目標是清除疾病的明顯徵兆並減少相關症狀，例如紅斑和搔癢。常常需要反覆治療或長期維持治療。(請參閱下文『預防復發』)
頭皮脂漏性皮膚炎 — 頭皮脂漏性皮膚炎可使用抗真菌洗髮精治療，根據皮膚炎嚴重程度，聯合或不聯合外用皮質類固醇(流程圖 1)。添加含有角質層分離劑（例如水楊酸）的洗髮精可能對厚鱗屑患者有幫助： ●輕度皮膚炎（頭皮屑）
－適用於頭皮輕度脂漏性皮膚炎，有瀰漫性、細小脫屑但無發炎（頭皮屑）的患者。 ），我們建議使用抗真菌洗髮精進行治療。抗真菌洗髮精包括 2% 酮康唑和 1% 環吡酮（可憑處方購買）以及 1% 吡啶硫酮鋅和 2.5% 硫化硒洗髮精（可在櫃檯購買）。
●中重度皮膚炎—對於有鱗屑、發炎和搔癢的中重度頭皮脂溢性皮膚炎患者，我們建議使用抗真菌洗髮精（例如2%酮康唑洗髮精）聯合高效外用皮質類固醇進行治療。（表1）採用患者選擇的配方（乳液、噴霧、泡沫或洗髮）。外用皮質類固醇可以每天使用，持續兩週，然後間歇性使用（例如每週兩次）。
●藥用洗髮精的使用和頻率 – 5至10毫升的洗髮精應保留3至5分鐘，然後沖洗掉。在初始治療階段，酮康唑洗髮精或其他抗真菌洗髮精應每週使用兩到三次，持續兩到四週。隨後，藥用洗髮精的使用可減少至每週一次，以防止復發[30]。抗真菌洗髮精常見輕微副作用，如刺激和/或灼熱感[31,32]。
患者有時會抱怨他們的洗髮精不再有效。鑑於馬拉色菌的某些菌株最終會對唑類抗真菌藥物產生抗藥性[19]，因此每隔幾週到幾個月輪換使用基於不同非唑類藥物的洗髮精可能是明智之舉。
含有水楊酸和煤焦油的洗髮精具有角質層分離特性，可能有助於軟化厚厚的鱗屑[33,34]。然而，焦油洗髮精很少使用，因為患者可能會發現焦油的氣味令人反感或擔心其潛在的致癌性[35]。
非頭皮脂漏性皮膚炎 — 我們治療非頭皮脂漏性皮膚炎的方法如演算法所示（演算法 2）。
臉部脂漏性皮膚炎— 對於臉部脂漏性皮膚炎患者，我們建議使用低效外用皮質類固醇乳膏（第6 組或第7 組（表1））、外用抗真菌劑（例如2% 酮康唑乳膏、其他唑乳膏、1% 環吡酮乳膏(表 2))，或兩者合併作為第一線治療(流程圖 2)。對於伴隨輕微紅斑和搔癢的輕度脂漏性皮膚炎患者，我們更喜歡單獨使用外用抗真菌藥物。對於有明顯紅斑和搔癢的患者，我們通常開始使用低效外用皮質類固醇治療，直到症狀消退或長達兩週，然後改用外用抗真菌藥物作為維持治療。如果病情突然發作，可以間歇性使用外用皮質類固醇。
應避免每天（超過兩週）在臉部長時間使用外用皮質類固醇，因為有局部不良反應（例如皮膚萎縮、毛細血管擴張）的風險。(參見「外用皮質類固醇的使用和不良反應」)
對於需要頻繁使用外用皮質類固醇的患者，外用鈣調神經磷酸酶抑製劑(0.1%他克莫司軟膏和1%吡美莫司乳膏)可作為替代治療，因為它們缺乏相關的不良反應。與局部皮質類固醇合用（例如皮膚萎縮、毛細血管擴張）[36-42]。
對於有鬍鬚的臉部脂漏性皮膚炎患者，我們建議每天用 2% 酮康唑洗髮，直到緩解，然後每週一次。可以在初始治療中添加低效皮質類固醇（第 7 組（表 1））以控制發炎和搔癢。
脂漏性瞼緣炎 — 眼瞼緣炎的治療，包括脂漏性瞼緣炎，將單獨討論。(請參閱“瞼緣炎”，關於‘治療’一節)
軀幹和間擦區域脂溢性皮膚炎— 對於軀幹和間擦區域脂溢性皮膚炎的患者，我們建議使用外用抗真菌藥物、外用皮質類固醇或合併用藥進行治療二（算法2）。局部抗真菌藥物每天一次或兩次塗抹在受影響的部位，直到症狀消退，然後間歇性地繼續使用，以防止復發。(請參閱下文『預防復發』)
外用皮質類固醇每天一次或兩次塗抹在受影響的部位，直到症狀消退，以避免潛在的不良反應。擦間部位應使用低效率外用皮質類固醇。中效外用皮質類固醇（表 1）可用於治療涉及胸部或上背部的脂漏性皮膚炎。對於間擦區域，外用鈣調神經磷酸酶抑制劑可以用作外用皮質類固醇的替代品。
HIV 感染者的脂漏性皮膚炎 — HIV 陽性患者的脂漏性皮膚炎更為瀰漫和嚴重，可能需要延長療程。目前尚無研究評估 HIV 陽性患者脂漏性皮膚炎的治療方法。初始治療與非愛滋病毒陽性患者相同[43,44]。對於嚴重病例或局部治療無效的病例，可能需要口服伊曲康唑一個療程（每天口服 200 毫克，持續一週）。
重度或難治性脂漏性皮膚炎— 口服抗黴菌藥物，包括伊曲康唑、酮康唑、氟康唑和特比萘芬，是治療涉及身體多個部位的脂漏性皮膚炎和局部治療無法充分控制的頑固性皮膚炎的一種治療選擇。其中，我們建議口服伊曲康唑。口服伊曲康唑，劑量為每天 200 mg，持續 7 天。
當明顯的脂漏性皮膚炎對適當的治療沒有反應時，應重新考慮診斷。(請參閱上文『鑑別診斷』)
共存脂漏性皮膚炎和紅斑性痤瘡 — 對於同時存在臉部脂漏性皮膚炎和紅斑性痤瘡的患者，對這兩種情況進行充分治療可能很困難。長期使用治療脂漏性皮膚炎的溫和外用皮質類固醇可能會加劇紅斑痤瘡，因此最好避免或非常謹慎和間歇性地使用。相較之下，外用 1% 甲硝唑凝膠或乳膏（用於紅斑痤瘡）也可能有助於緩解輕度脂漏性皮膚炎。
對於患有丘疹膿皰性紅斑痤瘡和臉部脂漏性皮膚炎的患者，外用壬二酸具有抗菌和抗真菌特性，被建議作為這兩種疾病的治療選擇[51]。(請參閱“紅斑痤瘡的治療”，關於‘外用壬二酸’一節)
一份病例報告描述了外用魯索替尼成功治療合併丘疹性紅斑痤瘡的頑固性脂溢性皮膚炎[52]。Ruxolitinib 是一種 Janus 激酶 (JAK) 抑制劑，可阻斷發炎級聯反應並減少 2 型輔助性 T (Th2) 驅動的細胞因子的產生。它已被批准用於治療 12 歲及以上非免疫功能低下患者的輕度至中度異位性皮膚炎，但已被超適應症用於治療其他發炎性皮膚病，例如白斑症和扁平苔癬。
MANAGEMENT
Topical antifungal agents (eg, ketoconazole, other azoles, ciclopirox olamine) are well established in the treatment of seborrheic dermatitis of the scalp and face because of their ability to decrease the population of Malassezia furfur on the affected skin and their anti-inflammatory property [28,29]. Topical anti-inflammatory agents (eg, topical corticosteroids, topical calcineurin inhibitors) are also frequently used for seborrheic dermatitis alone or in combination with topical antifungals.
Goal of treatment — Seborrheic dermatitis is a chronic condition. The main goal of therapy is to clear the visible signs of the disease and reduce associated symptoms, such as erythema and pruritus. Repeated treatment or long-term maintenance treatment is often necessary. (See 'Prevention of relapse' below.)
Seborrheic dermatitis of the scalp — Seborrheic dermatitis of the scalp is managed with antifungal shampoos, with or without topical corticosteroids, depending on dermatitis severity (algorithm 1). The addition of a shampoo containing a keratolytic agent (eg, salicylic acid) may be helpful for patients with thick scale:
●Mild dermatitis (dandruff) – For patients with mild seborrheic dermatitis of the scalp who have diffuse, fine desquamation without inflammation (dandruff), we suggest treatment with an antifungal shampoo. Antifungal shampoos include ketoconazole 2% and ciclopirox 1% (available by prescription) and zinc pyrithione 1% and selenium sulfide 2.5% shampoo (available over the counter).
●Moderate to severe dermatitis – For patients with moderate to severe seborrheic dermatitis of the scalp who have scale, inflammation, and pruritus, we suggest treatment with an antifungal shampoo (eg, ketoconazole 2% shampoo) in combination with a high-potency topical corticosteroid (table 1) in a formulation (lotion, spray aerosol, foam, or shampoo) of the patient's choice. Topical corticosteroids can be used daily for two weeks and then intermittently (eg, twice weekly).
●Use and frequency of medicated shampoos – Five to 10 mL of shampoo should be left on for three to five minutes before rinsing off. Ketoconazole shampoo or other antifungal shampoos should be used two to three times per week for two to four weeks in the initial treatment phase. Subsequently, the use of the medicated shampoo can be reduced to once a week to prevent relapse [30]. Minor adverse effects, such as irritation and/or burning sensation, are common with antifungal shampoo [31,32].
Patients sometimes complain that their shampoo is no longer effective. Given that some strains of Malassezia eventually become resistant to azole antifungals [19], it may be wise to effectuate, every few weeks to months, a rotation among shampoos based on different nonazole agents.
Shampoos containing salicylic acid and coal tar have keratolytic properties and may be helpful in softening thick scales [33,34]. Tar shampoos, however, are infrequently used as patients may find the odor of tar objectionable or be concerned about its potential carcinogenicity [35].
Nonscalp seborrheic dermatitis — Our approach to the management of nonscalp seborrheic dermatitis is illustrated in the algorithm (algorithm 2).
Seborrheic dermatitis of the face — For patients with seborrheic dermatitis of the face, we suggest treatment with a low-potency topical corticosteroid cream (groups 6 or 7 (table 1)), a topical antifungal agent (eg, ketoconazole 2% cream, other azole creams, ciclopirox 1% cream (table 2)), or a combination of the two as first-line treatment (algorithm 2). In patients with mild seborrheic dermatitis with minimal erythema and pruritus, we prefer to use topical antifungals alone. In patients with marked erythema and pruritus, we typically start treatment with a low-potency topical corticosteroid until symptoms subside or up to two weeks and then switch to topical antifungals as maintenance treatment. Topical corticosteroids can be used intermittently in case of flare-up.
Prolonged daily use (over two weeks) of topical corticosteroids on the face should be avoided due to the risk of local adverse effects (eg, skin atrophy, telangiectasias). (See "Topical corticosteroids: Use and adverse effects".)
In patients requiring frequent use of topical corticosteroids, topical calcineurin inhibitors (tacrolimus 0.1% ointment and pimecrolimus 1% cream) may be used as an alternative treatment, as they lack adverse effects associated with topical corticosteroids (eg, skin atrophy, telangiectasias) [36-42].
For patients with seborrheic dermatitis of the face who have mustaches and beards, we suggest ketoconazole 2% shampooing of the facial hair daily until remission and then once per week. A low-potency corticosteroid (group 7 (table 1)) can be added to the initial treatment to control inflammation and itching.
Seborrheic blepharitis — The management of blepharitis, including seborrheic blepharitis, is discussed separately. (See "Blepharitis", section on 'Management'.)
Seborrheic dermatitis of the trunk and intertriginous areas — For patients with seborrheic dermatitis of the trunk and intertriginous areas, we suggest treatment with topical antifungal agents, topical corticosteroids, or a combination of the two (algorithm 2). Topical antifungal agents are applied to affected areas once or twice daily until symptoms subside and then continued intermittently to prevent relapses. (See 'Prevention of relapse' below.)
Topical corticosteroids are applied to the affected areas once or twice daily only until symptoms subside to avoid potential adverse effects. A low-potency topical corticosteroid should be used in the intertriginous areas. Medium-potency topical corticosteroids (table 1) can be used for seborrheic dermatitis involving the chest or the upper back. For intertriginous areas, topical calcineurin inhibitors can be used as an alternative to topical corticosteroids.
Seborrheic dermatitis in patients with HIV infection — Seborrheic dermatitis is more diffuse and severe in patients who are HIV positive and may require a prolonged course of treatment. There are no studies evaluating the treatment of seborrheic dermatitis in patients who are HIV positive. Initial management is the same as for patients who are not HIV positive [43,44]. In severe cases or in cases that are refractory to topical treatment, a course of oral itraconazole (200 mg/day orally for one week) may be warranted.
Severe or refractory seborrheic dermatitis — Oral antifungal agents, including itraconazole, ketoconazole, fluconazole, and terbinafine, are a treatment option for seborrheic dermatitis involving multiple body areas and for recalcitrant dermatitis that is not adequately controlled with topical therapies. Among these, we suggest oral itraconazole. Oral itraconazole is given at the dose of 200 mg per day for seven days.
Whenever apparent seborrheic dermatitis does not respond to appropriate therapy, the diagnosis should be reconsidered. (See 'Differential diagnosis' above.)
Coexistent seborrheic dermatitis and rosacea — In patients with coexistent facial seborrheic dermatitis and rosacea, adequate treatment of both conditions may be difficult. Prolonged use of even mild topical corticosteroids prescribed for seborrheic dermatitis may exacerbate rosacea and should ideally be avoided or used very sparingly and intermittently. By contrast, topical metronidazole 1% gel or cream (used for rosacea) may also help mild seborrheic dermatitis.
In patients who have papulopustular rosacea and facial seborrheic dermatitis, topical azelaic acid, which has antibacterial and antifungal properties, has been suggested as a treatment option for both conditions [51]. (See "Management of rosacea", section on 'Topical azelaic acid'.)
A case report describes the successful use of topical ruxolitinib in the treatment of recalcitrant seborrheic dermatitis combined with papular rosacea [52]. Ruxolitinib is a Janus kinase (JAK) inhibitor that blocks the inflammatory cascade and decreases the production of T helper type 2 (Th2)-driven cytokines. It is approved for the treatment of mild to moderate atopic dermatitis in nonimmunocompromised patients 12 years of age and older but has been used off-label to treat other inflammatory skin diseases, such as vitiligo and lichen planus.
外用抗真菌藥物（例如酮康唑、其他唑類、環吡酮胺）在治療頭皮和臉部脂漏性皮膚炎方面已得到很好的應用。它們減少受影響皮膚上糠秕馬拉色菌數量的能力及其抗炎特性[28,29]。局部抗發炎藥物（例如局部皮質類固醇、局部鈣調神經磷酸酶抑制劑）也常單獨或與局部抗真菌藥物聯合用於治療脂漏性皮膚炎。
治療目標 — 脂漏性皮膚炎是一種慢性疾病。治療的主要目標是清除疾病的明顯徵兆並減少相關症狀，例如紅斑和搔癢。常常需要反覆治療或長期維持治療。(請參閱下文『預防復發』)
頭皮脂漏性皮膚炎 — 頭皮脂漏性皮膚炎可使用抗真菌洗髮精治療，根據皮膚炎嚴重程度，聯合或不聯合外用皮質類固醇(流程圖 1)。添加含有角質層分離劑（例如水楊酸）的洗髮精可能對厚鱗屑患者有幫助： ●輕度皮膚炎（頭皮屑）
－適用於頭皮輕度脂漏性皮膚炎，有瀰漫性、細小脫屑但無發炎（頭皮屑）的患者。 ），我們建議使用抗真菌洗髮精進行治療。抗真菌洗髮精包括 2% 酮康唑和 1% 環吡酮（可憑處方購買）以及 1% 吡啶硫酮鋅和 2.5% 硫化硒洗髮精（可在櫃檯購買）。
●中重度皮膚炎—對於有鱗屑、發炎和搔癢的中重度頭皮脂溢性皮膚炎患者，我們建議使用抗真菌洗髮精（例如2%酮康唑洗髮精）聯合高效外用皮質類固醇進行治療。（表1）採用患者選擇的配方（乳液、噴霧、泡沫或洗髮）。外用皮質類固醇可以每天使用，持續兩週，然後間歇性使用（例如每週兩次）。
●藥用洗髮精的使用和頻率 – 5至10毫升的洗髮精應保留3至5分鐘，然後沖洗掉。在初始治療階段，酮康唑洗髮精或其他抗真菌洗髮精應每週使用兩到三次，持續兩到四週。隨後，藥用洗髮精的使用可減少至每週一次，以防止復發[30]。抗真菌洗髮精常見輕微副作用，如刺激和/或灼熱感[31,32]。
患者有時會抱怨他們的洗髮精不再有效。鑑於馬拉色菌的某些菌株最終會對唑類抗真菌藥物產生抗藥性[19]，因此每隔幾週到幾個月輪換使用基於不同非唑類藥物的洗髮精可能是明智之舉。
含有水楊酸和煤焦油的洗髮精具有角質層分離特性，可能有助於軟化厚厚的鱗屑[33,34]。然而，焦油洗髮精很少使用，因為患者可能會發現焦油的氣味令人反感或擔心其潛在的致癌性[35]。
非頭皮脂漏性皮膚炎 — 我們治療非頭皮脂漏性皮膚炎的方法如演算法所示（演算法 2）。
臉部脂漏性皮膚炎— 對於臉部脂漏性皮膚炎患者，我們建議使用低效外用皮質類固醇乳膏（第6 組或第7 組（表1））、外用抗真菌劑（例如2% 酮康唑乳膏、其他唑乳膏、1% 環吡酮乳膏(表 2))，或兩者合併作為第一線治療(流程圖 2)。對於伴隨輕微紅斑和搔癢的輕度脂漏性皮膚炎患者，我們更喜歡單獨使用外用抗真菌藥物。對於有明顯紅斑和搔癢的患者，我們通常開始使用低效外用皮質類固醇治療，直到症狀消退或長達兩週，然後改用外用抗真菌藥物作為維持治療。如果病情突然發作，可以間歇性使用外用皮質類固醇。
應避免每天（超過兩週）在臉部長時間使用外用皮質類固醇，因為有局部不良反應（例如皮膚萎縮、毛細血管擴張）的風險。(參見「外用皮質類固醇的使用和不良反應」)
對於需要頻繁使用外用皮質類固醇的患者，外用鈣調神經磷酸酶抑製劑(0.1%他克莫司軟膏和1%吡美莫司乳膏)可作為替代治療，因為它們缺乏相關的不良反應。與局部皮質類固醇合用（例如皮膚萎縮、毛細血管擴張）[36-42]。
對於有鬍鬚的臉部脂漏性皮膚炎患者，我們建議每天用 2% 酮康唑洗髮，直到緩解，然後每週一次。可以在初始治療中添加低效皮質類固醇（第 7 組（表 1））以控制發炎和搔癢。
脂漏性瞼緣炎 — 眼瞼緣炎的治療，包括脂漏性瞼緣炎，將單獨討論。(請參閱“瞼緣炎”，關於‘治療’一節)
軀幹和間擦區域脂溢性皮膚炎— 對於軀幹和間擦區域脂溢性皮膚炎的患者，我們建議使用外用抗真菌藥物、外用皮質類固醇或合併用藥進行治療二（算法2）。局部抗真菌藥物每天一次或兩次塗抹在受影響的部位，直到症狀消退，然後間歇性地繼續使用，以防止復發。(請參閱下文『預防復發』)
外用皮質類固醇每天一次或兩次塗抹在受影響的部位，直到症狀消退，以避免潛在的不良反應。擦間部位應使用低效率外用皮質類固醇。中效外用皮質類固醇（表 1）可用於治療涉及胸部或上背部的脂漏性皮膚炎。對於間擦區域，外用鈣調神經磷酸酶抑制劑可以用作外用皮質類固醇的替代品。
HIV 感染者的脂漏性皮膚炎 — HIV 陽性患者的脂漏性皮膚炎更為瀰漫和嚴重，可能需要延長療程。目前尚無研究評估 HIV 陽性患者脂漏性皮膚炎的治療方法。初始治療與非愛滋病毒陽性患者相同[43,44]。對於嚴重病例或局部治療無效的病例，可能需要口服伊曲康唑一個療程（每天口服 200 毫克，持續一週）。
重度或難治性脂漏性皮膚炎— 口服抗黴菌藥物，包括伊曲康唑、酮康唑、氟康唑和特比萘芬，是治療涉及身體多個部位的脂漏性皮膚炎和局部治療無法充分控制的頑固性皮膚炎的一種治療選擇。其中，我們建議口服伊曲康唑。口服伊曲康唑，劑量為每天 200 mg，持續 7 天。
當明顯的脂漏性皮膚炎對適當的治療沒有反應時，應重新考慮診斷。(請參閱上文『鑑別診斷』)
共存脂漏性皮膚炎和紅斑性痤瘡 — 對於同時存在臉部脂漏性皮膚炎和紅斑性痤瘡的患者，對這兩種情況進行充分治療可能很困難。長期使用治療脂漏性皮膚炎的溫和外用皮質類固醇可能會加劇紅斑痤瘡，因此最好避免或非常謹慎和間歇性地使用。相較之下，外用 1% 甲硝唑凝膠或乳膏（用於紅斑痤瘡）也可能有助於緩解輕度脂漏性皮膚炎。
對於患有丘疹膿皰性紅斑痤瘡和臉部脂漏性皮膚炎的患者，外用壬二酸具有抗菌和抗真菌特性，被建議作為這兩種疾病的治療選擇[51]。(請參閱“紅斑痤瘡的治療”，關於‘外用壬二酸’一節)
一份病例報告描述了外用魯索替尼成功治療合併丘疹性紅斑痤瘡的頑固性脂溢性皮膚炎[52]。Ruxolitinib 是一種 Janus 激酶 (JAK) 抑制劑，可阻斷發炎級聯反應並減少 2 型輔助性 T (Th2) 驅動的細胞因子的產生。它已被批准用於治療 12 歲及以上非免疫功能低下患者的輕度至中度異位性皮膚炎，但已被超適應症用於治療其他發炎性皮膚病，例如白斑症和扁平苔癬。
MANAGEMENT
Topical antifungal agents (eg, ketoconazole, other azoles, ciclopirox olamine) are well established in the treatment of seborrheic dermatitis of the scalp and face because of their ability to decrease the population of Malassezia furfur on the affected skin and their anti-inflammatory property [28,29]. Topical anti-inflammatory agents (eg, topical corticosteroids, topical calcineurin inhibitors) are also frequently used for seborrheic dermatitis alone or in combination with topical antifungals.
Goal of treatment — Seborrheic dermatitis is a chronic condition. The main goal of therapy is to clear the visible signs of the disease and reduce associated symptoms, such as erythema and pruritus. Repeated treatment or long-term maintenance treatment is often necessary. (See 'Prevention of relapse' below.)
Seborrheic dermatitis of the scalp — Seborrheic dermatitis of the scalp is managed with antifungal shampoos, with or without topical corticosteroids, depending on dermatitis severity (algorithm 1). The addition of a shampoo containing a keratolytic agent (eg, salicylic acid) may be helpful for patients with thick scale:
●Mild dermatitis (dandruff) – For patients with mild seborrheic dermatitis of the scalp who have diffuse, fine desquamation without inflammation (dandruff), we suggest treatment with an antifungal shampoo. Antifungal shampoos include ketoconazole 2% and ciclopirox 1% (available by prescription) and zinc pyrithione 1% and selenium sulfide 2.5% shampoo (available over the counter).
●Moderate to severe dermatitis – For patients with moderate to severe seborrheic dermatitis of the scalp who have scale, inflammation, and pruritus, we suggest treatment with an antifungal shampoo (eg, ketoconazole 2% shampoo) in combination with a high-potency topical corticosteroid (table 1) in a formulation (lotion, spray aerosol, foam, or shampoo) of the patient's choice. Topical corticosteroids can be used daily for two weeks and then intermittently (eg, twice weekly).
●Use and frequency of medicated shampoos – Five to 10 mL of shampoo should be left on for three to five minutes before rinsing off. Ketoconazole shampoo or other antifungal shampoos should be used two to three times per week for two to four weeks in the initial treatment phase. Subsequently, the use of the medicated shampoo can be reduced to once a week to prevent relapse [30]. Minor adverse effects, such as irritation and/or burning sensation, are common with antifungal shampoo [31,32].
Patients sometimes complain that their shampoo is no longer effective. Given that some strains of Malassezia eventually become resistant to azole antifungals [19], it may be wise to effectuate, every few weeks to months, a rotation among shampoos based on different nonazole agents.
Shampoos containing salicylic acid and coal tar have keratolytic properties and may be helpful in softening thick scales [33,34]. Tar shampoos, however, are infrequently used as patients may find the odor of tar objectionable or be concerned about its potential carcinogenicity [35].
Nonscalp seborrheic dermatitis — Our approach to the management of nonscalp seborrheic dermatitis is illustrated in the algorithm (algorithm 2).
Seborrheic dermatitis of the face — For patients with seborrheic dermatitis of the face, we suggest treatment with a low-potency topical corticosteroid cream (groups 6 or 7 (table 1)), a topical antifungal agent (eg, ketoconazole 2% cream, other azole creams, ciclopirox 1% cream (table 2)), or a combination of the two as first-line treatment (algorithm 2). In patients with mild seborrheic dermatitis with minimal erythema and pruritus, we prefer to use topical antifungals alone. In patients with marked erythema and pruritus, we typically start treatment with a low-potency topical corticosteroid until symptoms subside or up to two weeks and then switch to topical antifungals as maintenance treatment. Topical corticosteroids can be used intermittently in case of flare-up.
Prolonged daily use (over two weeks) of topical corticosteroids on the face should be avoided due to the risk of local adverse effects (eg, skin atrophy, telangiectasias). (See "Topical corticosteroids: Use and adverse effects".)
In patients requiring frequent use of topical corticosteroids, topical calcineurin inhibitors (tacrolimus 0.1% ointment and pimecrolimus 1% cream) may be used as an alternative treatment, as they lack adverse effects associated with topical corticosteroids (eg, skin atrophy, telangiectasias) [36-42].
For patients with seborrheic dermatitis of the face who have mustaches and beards, we suggest ketoconazole 2% shampooing of the facial hair daily until remission and then once per week. A low-potency corticosteroid (group 7 (table 1)) can be added to the initial treatment to control inflammation and itching.
Seborrheic blepharitis — The management of blepharitis, including seborrheic blepharitis, is discussed separately. (See "Blepharitis", section on 'Management'.)
Seborrheic dermatitis of the trunk and intertriginous areas — For patients with seborrheic dermatitis of the trunk and intertriginous areas, we suggest treatment with topical antifungal agents, topical corticosteroids, or a combination of the two (algorithm 2). Topical antifungal agents are applied to affected areas once or twice daily until symptoms subside and then continued intermittently to prevent relapses. (See 'Prevention of relapse' below.)
Topical corticosteroids are applied to the affected areas once or twice daily only until symptoms subside to avoid potential adverse effects. A low-potency topical corticosteroid should be used in the intertriginous areas. Medium-potency topical corticosteroids (table 1) can be used for seborrheic dermatitis involving the chest or the upper back. For intertriginous areas, topical calcineurin inhibitors can be used as an alternative to topical corticosteroids.
Seborrheic dermatitis in patients with HIV infection — Seborrheic dermatitis is more diffuse and severe in patients who are HIV positive and may require a prolonged course of treatment. There are no studies evaluating the treatment of seborrheic dermatitis in patients who are HIV positive. Initial management is the same as for patients who are not HIV positive [43,44]. In severe cases or in cases that are refractory to topical treatment, a course of oral itraconazole (200 mg/day orally for one week) may be warranted.
Severe or refractory seborrheic dermatitis — Oral antifungal agents, including itraconazole, ketoconazole, fluconazole, and terbinafine, are a treatment option for seborrheic dermatitis involving multiple body areas and for recalcitrant dermatitis that is not adequately controlled with topical therapies. Among these, we suggest oral itraconazole. Oral itraconazole is given at the dose of 200 mg per day for seven days.
Whenever apparent seborrheic dermatitis does not respond to appropriate therapy, the diagnosis should be reconsidered. (See 'Differential diagnosis' above.)
Coexistent seborrheic dermatitis and rosacea — In patients with coexistent facial seborrheic dermatitis and rosacea, adequate treatment of both conditions may be difficult. Prolonged use of even mild topical corticosteroids prescribed for seborrheic dermatitis may exacerbate rosacea and should ideally be avoided or used very sparingly and intermittently. By contrast, topical metronidazole 1% gel or cream (used for rosacea) may also help mild seborrheic dermatitis.
In patients who have papulopustular rosacea and facial seborrheic dermatitis, topical azelaic acid, which has antibacterial and antifungal properties, has been suggested as a treatment option for both conditions [51]. (See "Management of rosacea", section on 'Topical azelaic acid'.)
A case report describes the successful use of topical ruxolitinib in the treatment of recalcitrant seborrheic dermatitis combined with papular rosacea [52]. Ruxolitinib is a Janus kinase (JAK) inhibitor that blocks the inflammatory cascade and decreases the production of T helper type 2 (Th2)-driven cytokines. It is approved for the treatment of mild to moderate atopic dermatitis in nonimmunocompromised patients 12 years of age and older but has been used off-label to treat other inflammatory skin diseases, such as vitiligo and lichen planus.
