An Overview of Seborrheic Dermatitis

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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 (the glands 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
  • Redness or pink-colored patches (mostly on people with darker skin)
  • Itchiness and burning

Adults who have seborrhea often experience outbreaks that come and go. Although the skin can take on an oily or greasy appearance, overall skin affected by this condition is actually quite dry.

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 across the skin, 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 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.

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 that can build up and irritate the skin, causing redness and flaking.

New research has shown that the Malassezia fungus may not be the only contributing factor. 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 the skin.)

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, though, that having a skin microbiome that is out of "balance," so to speak, contributes to the irritation and flaking. In short, it's likely that seborrheic dermatitis isn't caused by one specific factor, but rather the skin's flora collectively.

Genetic Factors

Other studies suggest that genetic factors, such as gene mutations or 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 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 with proper maintenance, which often includes over-the-counter (OTC) treatments such as antifungal shampoos. Natural remedies may also be helpful. Many of the treatments that work for adults, including antiseborrheic or anti-dandruff shampoos and OTC steroid cream or lotion, can work for infants, too.

Soaps and Shampoos

Frequent washing with antifungal soap and shampoos 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)
  • Pyrithione zinc (found in Head & Shoulders)
  • Sebulon, which is coal tar (found in Sebutone and Tegrin)
  • Ketoconazole (found in Nizoral)

All of these shampoos have a medicated smell. 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.

Moisturizers

Keeping the skin well-moisturized is another key component to managing seborrheic dermatitis. Consistent use of moisturizing products helps with the symptoms of 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.

There are a few prescription creams that are non-steroidal, anti-fungal, anti-inflammatory moisturizers available specifically for seborrheic dermatitis. These include:

  • Promiseb
  • EpiCeram
  • Nutraceb

Over-the-counter moisturizers that contain ceramides are another option. When choosing a moisturizing product, you should read the ingredient listing. 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 scalp). If the hair looks greasy in the morning, you can shampoo it away.

Topical Steroids 

Topical steroids reduce the inflammatory response and help control itching. These should not be used as a first-line treatment for seborrheic dermatitis. Instead, 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 area until the redness resolves.

Don't use OTC hydrocortisone on infants without a recommendation by your doctor. For everyone, hydrocortisone should not be used for more than four weeks.

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

Depending on the severity of your seborrhea, your doctor might recommend a stronger, prescription hydrocortisone, including Capex or Synalar (fluocinolone), Clobex, or Cormax (clobetasol), or Desowen or Desonate (desonide).

Again, these should be used for short periods of time only. 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 where there is a lot of inflammation or thick layers of flakes. These non-corticosteroid medications can be used in children (ages two 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 flareups. 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, honey has been shown to prevent the growth of Staphylococcus aureus.

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

Altogether, these qualities would 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% honey and 10% warm water to affected areas. The mixture was left on for three hours before rinsing 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, there was a very small sample size of 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. Since research is still limited, it might be worth talking to your dermatologist before adding one of these to your self-care routine.

Unless you have allergies, to say tree nuts, fish, or honey, it likely won't hurt you to give them a try. 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 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 periods.

A few more lifestyle modifications to keep in mind:

  • Check the ingredients. Until your seborrheic dermatitis gets under control, it is smart to skip any shampoos, conditioners, or styling products (sprays, gels, dry shampoos) that contain alcohol, which can irritate your scalp.
  • 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 first rubbing in a little mineral oil into the scalp. Leave it on for 10 to 15 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 will 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

Embarrassment from facial redness and scaling or flakes on your clothing, to annoying itching, seborrheic dermatitis can be frustrating to deal with.

It's normal to feel embarrassed about your skin condition; 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 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 and live a flake- and itchy-free life.

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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


  3. Molan P, Rhodes T. Honey: A Biologic Wound Dressing. Wounds. 2015 Jun;27(6):141-51.


  4. McLoone P, Warnock M, Fyfe L. Honey: A realistic antimicrobial for disorders of the skin. J Microbiol Immunol Infect. 2016 Apr;49(2):161-7. doi:10.1016/j.jmii.2015.01.009


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