1000-2000 5 ьшò

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Recheck weekly until clear, then at times of recurrence.

PATIENT EDUCATION

Patient education is vital to the treatment and prevention of recurrent cases.

PROGNOSIS

Quick, complete clearing with appropriate treatment

Secondary candidal infections may last a few weeks after treatment has begun.

COMPLICATIONS

Secondary bacterial infection (Consider community-acquired methicillinresistant Staphylococcus aureus [MRSA] in pustular dermatitis that does not respond to normal therapy.)

Rare complication is inoculation with group Aβ-hemolytic Streptococcus resulting in necrotizing fasciitis.

Secondary yeast infection

REFERENCES

1.Stamatas GN, Tierney NK. Diaper dermatitis: etiology, manifestations, prevention, and management. Pediatr Dermatol. 2014;31(1):1–7.

2.Erasala GN, Romain C, Merlay I. Diaper area and disposable diapers. Curr Probl Dermatol. 2011;40:83–89.

3.Lavender T, Furber C, Campbell M, et al. Effect on skin hydration of using baby wipes to clean the napkin area of newborn babies: assessor-blinded randomised controlled equivalence trial. BMC Pediatr. 2012;12:59.

4.Humphrey S, Bergman JN, Au S. Practical management strategies for diaper dermatitis. Skin Therapy Lett. 2006;11(7):1–6.

ADDITIONALREADING

Qiao XP, Ge YZ. Clinical effect of hydrocolloid dressings in prevention and treatment of infant diaper rash. Exp Ther Med. 2016;12(6):3665–3669.

SEE ALSO

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Algorithm: Rash

CODES

ICD10

L22 Diaper dermatitis

B37.2 Candidiasis of skin and nail

CLINICALPEARLS

Hygiene is the main preventative measure. Look for secondary infection in persistent cases.

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DERMATITIS, SEBORRHEIC

Juan Qiu, MD, PhD

BASICS

DESCRIPTION

Chronic, superficial, recurrent inflammatory rash affecting sebum-rich, hairy regions of the body, especially the scalp, eyebrows, and face

EPIDEMIOLOGY

Incidence

Predominant age: infancy, adolescence, and adulthood

Predominant sex: male > female

Prevalence

Seborrheic dermatitis: 3–5%

ETIOLOGYAND PATHOPHYSIOLOGY

Skin surface yeasts Malassezia may be a contributing factor (1).

Genetic and environmental factors: Flares are common with stress/illness.

Parallels increased sebaceous gland activity in infancy and adolescence or as a result of some acnegenic drugs.

Seborrheic dermatitis is more common in immunosuppressed patients, suggesting that immune mechanisms are implicated in the pathogenesis of the disease, although the mechanisms are not well defined (1).

Genetics

Positive family history; no genetic marker is identified to date.

RISK FACTORS

Parkinson disease, epilepsy, traumatic brain and spinal cord injury, Down syndrome (1)

AIDS, lymphoma, organ transplantation (1)

Emotional stress (1)

Medications may flare/induce seborrheic dermatitis: buspirone, chlorpromazine, ethionamide, griseofulvin, haloperidol, interferon-α,

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methyldopa, psoralen, IL-2 (1)

GENERALPREVENTION

Seborrheic skin should be washed more often than usual.

COMMONLYASSOCIATED CONDITIONS

Parkinson disease AIDS

DIAGNOSIS

Diagnosis of seborrheic dermatitis usually can be made by history and physical exam.

HISTORY

Intermittent active phases manifest with burning, scaling, and itching, alternating with inactive periods; activity is increased in winter and early spring, with remissions commonly occurring in summer.

Infants

–Cradle cap: greasy scaling of scalp, sometimes with associated mild erythema

–Diaper and/or axillary rash

–Age at onset typically ~1 month

–Usually resolves by 8 to 12 months

Adults

–Red, greasy, scaling rash in most locations consisting of patches and plaques with indistinct margins

–Red, smooth, glazed appearance in skin folds

–Minimal pruritus

–Chronic waxing and waning course

–Bilateral and symmetric

–Most commonly located in hairy skin areas: scalp and scalp margins, eyebrows and eyelid margins, nasolabial folds, ears and retroauricular folds, presternal area, middle to upper back, buttock crease, inguinal area, genitals, and armpits

PHYSICALEXAM

Scalp appearance varies from mild, patchy scaling to widespread, thick,

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adherent crusts. Plaques are rare.

Seborrheic dermatitis can spread onto the forehead, the posterior part of the neck, and the postauricular skin, as in psoriasis.

Skin lesions manifest as brawny or greasy scaling over red, inflamed skin.

Hypopigmentation is seen in African Americans.

Infectious eczematoid dermatitis, with oozing and crusting, suggests secondary infection.

Seborrheic blepharitis may occur independently.

DIFFERENTIALDIAGNOSIS

Atopic dermatitis: Distinction may be difficult in infants. Psoriasis

–Usually, knees, elbows, and nails are involved.

–Scalp psoriasis will be more sharply demarcated than seborrhea, with crusted, infiltrated plaques rather than mild scaling and erythema.

Candida

Tinea cruris/capitis: Suspect these when usual medications fail or hair loss occurs.

Eczema of auricle/otitis externa

Rosacea

Discoid lupus erythematosus: Skin biopsy will be beneficial.

Histiocytosis X: may appear as seborrheic-type eruption

Dandruff: scalp only, noninflammatory

DIAGNOSTIC TESTS & INTERPRETATION

Diagnostic Procedures/Other

Consider biopsy if

Usual therapies fail.

Petechiae are noted.

Histiocytosis X is suspected.

Fungal cultures in refractory cases or when pustules and alopecia are present

Test Interpretation

Nonspecific changes

Hyperkeratosis, acanthosis, accentuated rete ridges, focal spongiosis, and parakeratosis are characteristic.

Parakeratotic scale around hair follicles and mild superficial inflammatory

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lymphocytic infiltrate

TREATMENT

GENERALMEASURES

Increase frequency of shampooing.

Sunlight in moderate doses may be helpful.

Cradle cap

–Frequent shampooing with a mild, nonmedicated shampoo

–Remove thick scale by applying warm mineral oil and then wash off 1 hour

later with a mild soap and a soft-bristle toothbrush or terrycloth washcloth. Adults: Wash all affected areas with antiseborrheic shampoos. Start with over-

the-counter products (selenium sulfide) and increase to more potent preparations (containing coal tar, sulfur, or salicylic acid) if no improvement is noted.

For dense scalp scaling, 10% liquor carbonic detergents in Nivea oil may be used at bedtime, covering the head with a shower cap. This should be done nightly for 1 to 3 weeks.

MEDICATION

First Line

Cradle cap: Use a coal tar shampoo or ketoconazole (Nizoral) shampoo if the nonmedicated shampoo is ineffective.

Adults

–Topical antifungal agents

Ketoconazole or miconazole 2% shampoo twice a week for clearance and then once a week or every other week for maintenance (1–3)[A]

Ketoconazole (Nizoral) and sertaconazole 2% cream may be used to clear scales in other areas (1–3)[A].

Ciclopirox 1% shampoo twice weekly (1–3)[A]

–Topical corticosteroids

Begin with 1% hydrocortisone and advance to more potent (fluorinated) steroid preparations, as needed (1–3)[A].

■Avoid continuous use of the more potent steroids to reduce the risk of skin atrophy, hypopigmentation, or systemic absorption (especially in infants and children).

■Precautions: Fluorinated corticosteroids and higher concentrations of

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hydrocortisone (e.g., 2.5%) may cause atrophy or striae if used on the face or on skin folds.

–Other topical agents

Coal tar 1% shampoo twice a week

Selenium sulfide 2.5% shampoo twice a week

Zinc pyrithione 1% shampoo twice a week

Lithium gluconate/succinate 8% ointment/gel twice a week (4)[A]

Once controlled, washing with zinc soaps or selenium lotion with periodic use of steroid cream may help to maintain remission.

Second Line

Calcineurin inhibitors

–Pimecrolimus 1% cream BID (4)[A]

–Tacrolimus 0.1% ointment (4)[A]

Systemic antifungal therapy

–Data are limited.

–For moderate to severe seborrheic dermatitis Ketoconazole: 200 mg/day (5)[A]

Itraconazole: 200 mg/day (5)[A]

Daily regimen for 1 to 2 months followed by twice-weekly dosing for chronic treatment

Monitor potential hepatotoxic effects.

Low-molecular-weight hyaluronic acid

– Hyaluronic acid sodium salt gel 0.2% BID (6)[B]

ISSUES FOR REFERRAL

No response to first-line therapy and concerns regarding systemic illness (e.g., HIV)

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Every 2 to 12 weeks, as necessary, depending on disease severity and degree of patient sophistication

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PATIENTEDUCATION

http://familydoctor.org/familydoctor/en/diseases-conditions/seborrheic- dermatitis.html

PROGNOSIS

In infants, seborrheic dermatitis usually remits after 6 to 8 months.

In adults, seborrheic dermatitis is usually chronic and unpredictable, with exacerbations and remissions. Disease is usually easily controlled with shampoos and topical steroids.

COMPLICATIONS

Skin atrophy/striae are possible from fluorinated corticosteroids, especially if used on the face.

Glaucoma can result from use of fluorinated steroids around the eyes.

Photosensitivity is caused occasionally by tars.

Herpes keratitis is a rare complication of herpes simplex: Instruct patient to stop eyelid steroids if herpes simplex develops.

REFERENCES

1.Borda LJ, Wikramanayake TC. Seborrheic dermatitis and dandruff: a comprehensive review. J Clin Investig Dermatol. 2015;3(2). doi:10.13188/2373-1044.1000019.

2.Clark GW, Pope SM, Jaboori KA. Diagnosis and treatment of seborrheic dermatitis. Am Fam Physician. 2015;91(3):185–190.

3.Okokon EO, Verbeek JH, Ruotsalainen JH, et al. Topical antifungals for seborrhoeic dermatitis. Cochrane Database Syst Rev. 2015;(5):CD008138.

4.Kastarinen H, Oksanen T, Okokon EO, et al. Topical anti-inflammatory agents for seborrhoeic dermatitis of the face or scalp. Cochrane Database Syst Rev. 2014;(5):CD009446.

5.Gupta AK, Richardson M, Paquet M. Systematic review of oral treatments for seborrheic dermatitis. J Eur Acad Dermatol Venereol. 2014;28(1):16–26.

6.Schlesinger T, Rowland Powell C. Efficacy and safety of a low molecular weight hyaluronic acid topical gel in the treatment of facial seborrheic dermatitis final report. J Clin Aesthet Dermatol. 2014;7(5):15–18.

ADDITIONALREADING

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Dessinioti C, Katsambas A. Seborrheic dermatitis: etiology, risk factors, and treatments: facts and controversies. Clin Dermatol. 2013;31(4):343–351.

Hay RJ. Malassezia, dandruff and seborrhoeic dermatitis: an overview. Br J Dermatol. 2011;165(Suppl 2):2–8.

Kim GK, Rosso JD. Topical pimecrolimus 1% cream in the treatment of seborrheic dermatitis. J Clin Aesthet Dermatol. 2013;6(2):29–35. Stefanaki I, Katsambas A. Therapeutic update on seborrheic dermatitis. Skin Therapy Lett. 2010;15(5):1–4.

SEE ALSO

Algorithm: Rash

CODES

ICD10

L21.9 Seborrheic dermatitis, unspecified

L21.1 Seborrheic infantile dermatitis

L21.0 Seborrhea capitis

CLINICALPEARLS

Search for an underlying systemic disease in a patient who is unresponsive to usual therapy.

In adults, seborrheic dermatitis is usually chronic and unpredictable, with exacerbations and remissions. Disease is usually easily controlled with shampoos and topical steroids.

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