An Overview of Seborrheic Dermatitis

A flaky, itchy scalp is a symptom of seborrhea.

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Seborrheic dermatitis is a chronic, inflammatory skin condition that affects the areas of the head and trunk that have sebaceous glands (those that create skin oil). It causes red, flaky skin around the nose, forehead, ears, in the eyebrows, and on the scalp. Seborrheic dermatitis is also called seborrhea; in infants, this condition is known by the household name cradle cap.

Symptoms

Symptoms most often appear on the scalp as dandruff, but seborrhea can also appear on other oily areas of the body like the eyebrows, nose, back, the upper portion of the chest, and in and around the ears, and the groin area.

While seborrheic dermatitis can look similar to psoriasis, rosacea, atopic dermatitis, and superficial fungal infections, it does have a few distinct symptoms, including:

  • Scaly white or yellow patches that flake off
  • Greasy-looking and swollen skin (although it is more often dry)
  • Redness or pink-colored patches (mostly on people with darker skin)
  • Itchiness and burning

In infants, seborrhea most often develops on the scalp and face, but it can sometimes develop in the diaper area and folds of the skin. It looks like a buildup of yellow flakes and is sometimes accompanied by reddened skin. In rare cases, babies can lose their hair in affected areas. In general, though, most cases of cradle cap don't bother babies and the condition is outgrown by the time they are a year old.

Seborrheic dermatitis isn't common during the childhood years but can return (or appear for the first time) during puberty and beyond. Adults who have seborrhea often experience outbreaks that come and go.

Causes

The exact cause of seborrheic dermatitis remains elusive. Several factors have been implicated. More than likely, it's a combination of several causes that contribute to the development of the condition.

The Skin's Microbiome

One possibility is the yeast-like fungus Malassezia (Pityrosporum). It is normally present on oily areas of the body without causing problems. People with seborrhea, however, produce higher levels of the fungus that can build up and irritate the skin, causing redness and flaking.

Research has shown that Malassezia may not be the only contributing factor, however. According to a 2017 review published in the European Journal of Dermatology, as well as a study published in Experimental Dermatology, the bacterial microbiome of the skin is different in those with seborrheic dermatitis compared to those without the condition. (The skin's microbiome is made up of all of the microorganisms that live on its surface.)

One specific bacterium that is more common in people with seborrheic dermatitis is Staphylococcus aureus. Staph is a normal resident of the skin, so having it does not mean that the skin is infected, nor is seborrhea caused by an infection. Staph, along with a weak skin barrier, work in tandem to lay the framework for seborrheic dermatitis development, according to at least one study.

The thought is that having a skin microbiome that is "out of balance," so to speak, contributes to irritation and flaking. But it's likely that seborrheic dermatitis is caused by the skin's flora collectively, rather than just one factor.

Genetic Factors

Other studies suggest that genetic factors, such as gene mutations and protein deficiencies, may also contribute to the development of the condition. These factors may play a role in the immune response or the way the skin carries out its functions.

A 2019 study, in particular, suggests that a defective skin barrier may be responsible for seborrheic dermatitis. The chemical makeup of sebum in those with seborrhea is different in those without the condition and may make a more favorable home for microbes such as Malassezia to take hold.

Triggers

Seborrheic dermatitis is typically triggered by factors like:

  • Stress
  • Sickness
  • Hormonal changes
  • Weather (cold, dry air)
  • Medications (psoralen, interferon, and lithium)

Seborrhea affects 3% of the general population and can occur at any age. It is more common in men, however, and often impacts patients with neurologic conditions (such as Parkinson's disease) and health conditions that compromise the immune system (such as HIV). Nearly 85% of people with AIDS experience seborrheic dermatitis.

Your risk also increases if you have one of the following health conditions:

  • Alcohol use disorder
  • Acne
  • Depression
  • Eating disorder
  • Epilepsy
  • Rosacea

Diagnosis

It usually just takes a medical history and physical exam to diagnose seborrheic dermatitis.

Sometimes, however, since seborrhea can look like (or appear with) other skin conditions, your doctor may need to scrape a bit of skin and mix it with a chemical to test for a fungal infection. This is called a skin scraping or a KOH prep test.

A skin biopsy might also be used to rule out or confirm any other conditions that have similar symptoms.

Treatment

Seborrhea cannot be cured, but it can be controlled. Doing so successfully requires a two-pronged approach: First, seborrhea-inducing yeast must be controlled. Second, skin care products must be carefully chosen to allow for healing, without feeding the yeast and allowing it to proliferate.

Many of the treatments that work for adults, including antiseborrheic or anti-dandruff shampoos and OTC steroid creams and lotions, can work for infants, too.

Soaps and Shampoos

Frequent washing with antifungal soap and shampoo gets rid of the oils in the affected areas and improves symptoms.

For the body, look for a gentle, daily cleanser with 2% zinc pyrithione, and moisturize with a cream that contains salicylic acid and sulfur, or coal tar.

For the scalp (dandruff), there are several good antifungal shampoos on the market that can be purchased without a prescription. Read the labels for the following ingredients:

  • Selenium sulfide (found in Selsun Blue)
  • Pyrithione zinc (found in Head & Shoulders)
  • Sebulon, which is coal tar (found in Sebutone and Tegrin)
  • Ketoconazole (found in Nizoral)

When you use one, lather the shampoo into your hair and scalp, leave it there for at least 10 minutes, and then rinse it off. These shampoos can be used on the face and other parts of the body as well; follow the same instructions, just be careful not to get it in your eyes.

Do this daily until the redness and flaking are controlled, then use the shampoo two to three times a week to keep symptoms from returning.

Note: All of these shampoos have a medicated smell.

Moisturizers

Keeping the skin well-moisturized is another key component to managing seborrheic dermatitis. Consistent use of moisturizing products helps with dryness, flaking, and itch.

What's more, moisturizers can help improve barrier function, which may be beneficial because seborrhea is linked to an impaired skin barrier.

Over-the-counter moisturizers that contain ceramides are helpful. When choosing a moisturizing product, read the ingredients list. Products that contain fatty acids, esters, or polysorbates can "feed" the Malassezia yeast, and encourage fungal growth.

Instead, look for moisturizers that contain:

  • Squalane (not to be confused with squalene)
  • MCT oil (AKA caprylic/capric triglycerides)
  • Mineral oil
  • Urea
  • Salicylic acid (not a moisturizing ingredient, but one that helps reduce dead skin buildup)

Some good brand options include CeraVe, Aveeno, and Eucerin.

For dandruff, you may try rubbing a small amount of moisturizing product into the scalp at night before bed (no need to apply to the hair, just the skin). If the hair looks greasy in the morning, you can shampoo it away.

Ask your doctor or pharmacist for skin/scalp care product recommendations if you need help.

Antifungal Creams

There are a few prescription non-steroidal, antifungal, anti-inflammatory creams available specifically for seborrheic dermatitis as well. These include:

  • Promiseb
  • EpiCeram
  • Nutraceb

Topical Steroids 

Topical steroids reduce the inflammatory response and help control itching. They may be used short-term to get an acute flareup under control. Long-term steroid use can cause side effects like acne and thinning of the skin.

Over-the-counter hydrocortisone cream (1%) can be used over most areas, including the face. Keep well away from the eyes, however. Apply it twice a day to the affected areas until the redness resolves.

Topical steroids should not be used as a first-line treatment for seborrheic dermatitis. When recommended, use should not exceed four weeks. Never use OTC hydrocortisone on infants unless suggested by a doctor.

In very specific cases, your doctor may recommend a stronger steroid or combination medication to help dissolve the dead skin. Some examples include:

  • Capex or Synalar (fluocinolone)
  • Clobex, or Cormax (clobetasol)
  • Desowen or Desonate (desonide)

Again, these should only be used for short periods of time. Once seborrhea is under control, you should switch to another treatment for maintenance.

Topical Calcineurin Inhibitors

A topical calcineurin inhibitor (TCI), such as Protopic (tacrolimus) or Elidel (pimecrolimus), may be prescribed in cases when there is a lot of inflammation or thick layers of flakes. These non-corticosteroid medications can be used in children (ages 2 and older), as well as adults. TCIs are used off-label for seborrheic dermatitis.

As with topical steroids, these medications are meant to be used for short periods of time for active flare-ups. They are typically prescribed when other treatments haven't yielded acceptable results.

Oral Medications

They aren't used very often, but oral medications may be prescribed in very severe cases that haven't responded well to topical treatments.

Oral antifungal agents (ketoconazole, itraconazole, and terbinafine) are most often used. In some cases, low-dose isotretinoin can be another option.

Raw Honey

Honey is probably the most well-studied natural remedy in dermatology. Honey has been shown to have antimicrobial and wound-healing properties. More specifically, it can prevent the growth of Staphylococcus aureus.

All types of honey have been shown to have antimicrobial effects, although potency varies between varieties by more than 100-fold, which may factor into their benefits. Some of the most potent types include Manuka and Scottish heather honey.

Honey is a humectant, which means it helps keep the skin hydrated. It also has anti-inflammatory properties.

Altogether, these qualities suggest that honey may have a positive effect on seborrheic dermatitis. In fact, some people have had marked improvement with using honey as a treatment.

In a 2001 study, people with seborrheic dermatitis of the face or scalp applied a mixture of 90% raw honey and 10% warm water to affected areas. The mixture was left on for three hours before rinsing it off with warm water. This was done every other day for four weeks.

Those who continued with a preventative, once-a-week treatment for six months continued to have no symptoms. Interestingly, those who did not continue with treatment throughout the six-month timeframe had relapsing symptoms within three months.

While the results of this study were exciting, the sample size was just 30 participants. Also, the constituents of honey vary depending on the type (i.e., which plants the bees are visiting to make the honey).

If you're interested in trying honey for treating your seborrheic dermatitis, first get advice from your physician or naturopathic doctor.

Other Natural Remedies

Many people also turn to natural remedies to help relieve symptoms and keep seborrhea at bay.

Unless you have allergies to, say, tree nuts, fish, or honey, it likely won't hurt you to give the following options a try. But since research is still limited, don't bank on these remedies for results. Keep your dermatologist abreast of any you work into your self-care routine; you can also consider discussing their integration with your doctor ahead of time.

Other ingredients often used for skin problems include:

Lifestyle Modifications

Beyond medication, controlling your triggers is a big part of preventing flares. Stress, for example, weakens your body’s immune system, making it difficult to deal with the build-up of Malassezia or an overabundance of other bacteria.

Sun exposure is also helpful, as sunlight not only boosts your mood and immunity but also inhibits the growth of the yeast. Don't overdo it, however. When you do spend time in the sun, don't forget sunscreen if you plan to be outdoors for longer than 30 minutes (15 to 20 minutes if the UV Index is higher than 7).

A few more lifestyle modifications to keep in mind:

  • Avoid products containing alcohol: Until your seborrheic dermatitis gets under control, it is smart to skip any shampoos, conditioners, or styling products (sprays, gels, dry shampoos) that contain this irritating ingredient.
  • Brush softly: Especially for babies with cradle cap, brushing the area regularly with a soft brush can help prevent the build-up of scales. Consider rubbing in a little mineral oil into the scalp first. Leave it on for 10 to 15 minutes to help soften the scales before brushing, then shampoo the oil out thoroughly.
  • Stick with cotton clothing: Depending on the location of your symptoms, soft cotton clothing can help reduce skin irritation and allow your skin to breathe.
  • Keep it clean: Baby shampoo is a great gentle cleanser for adults, too. Use it nightly to wash away any scales on your eyelids.

Coping

The facial redness, scaling, flakes on your clothing, and chronic itching that seborrheic dermatitis can cause can be frustrating to deal with—and even embarrassing.

It's understandable to feel this way; many people with seborrheic dermatitis do. But if you are feeling depressed or anxious to the point that it is interfering with your daily life, let your doctor know. More aggressive skin treatment can help you feel better about yourself. There are also treatments to help improve depression and anxiety.

Finding support can help you feel better, as well. Ask your doctor if there are local support groups that meet near you, or look online through organizations such as the National Eczema Association.

A Word From Verywell

While seborrheic dermatitis is chronic, it can be controlled. If over-the-counter products and lifestyle modifications aren’t working and you are experiencing frequent flares, make an appointment with your dermatologist ASAP. Together, you can come up with a plan to manage your symptoms.

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Article Sources

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  2. Paulino LC. New perspectives on dandruff and seborrheic dermatitis: lessons we learned from bacterial and fungal skin microbiota. Eur J Dermatol. 2017 Jun 1;27(S1):4-7. doi:10.1684/ejd.2017.3038


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