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 Anwar, M.B.B.S[3]

Synonyms and keywords: Seborrheic eczema

Overview

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

Historical Perspective

Classification

There is no established classification system for seborrheic dermatitis.However, seborrheic dermatitis can be classified on the basis of following factors:[1][2][3][4]

  • Localised
    • Scalp: In infants its called Cradle Cap. Its the most common presentation in infants and appear as red yellow plaques coated by thick greasy scales, commonly appearing in first three months of age.In adults, presentation of disease is mild desquamationto honey coloured crusts which can extend to involve forehead called "corona seborrheica"
    • Face: It most commonly involves eyelids, eyebrows and nasolabial folds. Eyes are involved resulting in blephritis.
    • Retroauricular: lt invloves crusting, oozing and fissuring in the affected area. It may also involve external ear resulting in otitis externa.
    • Body folds: It usually affects axilla, breast folds, inguinal area and genital area. May progress to fissuring and secondary infection.
    • Upper Chest: It is mostly seen in adults. Affected areas may present with one of the following presentation.
      • Pityriasiform: It is usually in the form oval macules and patches ranging from 5-15mm in size which tend to involve intertriginous areas.
      • Petaloid type: It appears as small papules with oily scales which enlarges to become patches giving it an appearance of petals of flower, hence the name.
    • Trunk: common in infants and most common site of involvement is lower abdomen.
  • Generalized: mostly seen in infants associated with leiner's disease and children with severe immunodeficiency. It usually is associated with diarrhea and failure to thrive and may resolve in few weeks.

Classification by Age

  • Infantile: seen in first three months of life. It is mostly a self limited disease in children.
  • Adults: occurs most commonly between 30-60 years of age. In adults, it usually appears as chronic relapsing condition invloving various parts of the body.

Classification by Symptomic Presentation

  • Non pruritic: This type is most commonly seen in infants.
  • Pruritic: This type is seen in older children and adults. This type is common with scalp involvement.

Classification by Etiology

Exact cause of seborrheic dermatitis is unknown.However, following causes may be related to pathogenesis of seborrheic dermatitis.

  • Idiopathic : No known cause
  • Infectious: Caused by fungus named Malssezia based on its response to antifungal agents.
  • Autoimmune/Inflammatory:One hypothesis suggests it as a primary inflammatory dermatoses resulting in increased apoptosis, scaling and inflammation in epidermis[[.

Classification by Severity

  • Mild to moderate disease: seen in immunocompetent individuals.
  • Severe disease: Immunocomprised patients have more extensive disease which is mostly unresponsive to treatment.

Pathophysiology

Complete pathogenesis of seborrheic dermatitis is not fully understood. However, studies have demonstrated strong correlation between presence of fungal yeast named Malasezia and seborrheic dermatitis.[5] Malasezia is a lipophilic yeast found on the skin of both healthy individuals and seborrheic dermatitis patients. The exact mechanism of disease process in individuals having seborrheic dermatitis is not established but it is thought that host reaction to Malasezia or its metabolites causing inflammatory reaction may have a significant role in the process. Two species of Malasezia named Malasezia globosa and Malasezia restricta may have a stronger association with the development of seborrheic dermatitis.[6]. Another proposed mechanism for seborrheic dermatitis may indicate that lipid layer of fungus Malassezia when disrupted leads to an inflammatory response resulting in increased production of pro inflammatory cytokines such as IL-6 and IL-7 and decreased production of IL-10. [7] However, there is no genetic predisposition for seborrheic dermatiti

Gross Pathology

Superficial flaking and redness are characteristic findings of seborrheic dermatitis. Flakes usually occur in patches on scalp and tend to move about scalp over time.[8]

  1. REDIRECTSeborrheic dermatis physical examination

Microscopic Histopathology

Histopathological findings of seborrheic dermatitis can be divided into three types based on the following types, [9][10]

Acute

Focal mild spongiosis with superficial crust containing neutrophils centered on a follicle, mild Edema of papillary dermis, dilatatiuon of blood vessels in superficial vascular plexus with mild infiltration of lymphocytes, histiocytes and occasional neutrophils are characteristic findings of seborrheic dermatitis.

Subacute

In addition to findings mentioned above, there is also some psoriasiform hyperplasia in subacute form of seborrheic dermatitis. This type may show presence of yeast like organisms in the surface keratin.

Chronic

Extensive psoriasiform hyperplasia and minimal spongiosis are characteristic findings seen in this type. This type resembles psoriasis and might be difficult to differentiate from psoriasis but presence of follicular crustiong favours seborrheic dermatitis.

Causes

The cause of seborrhoeic dermatitis remains unknown, although many factors have been implicated. The widely present yeast, Malassezia furfur (formerly known as Pityrosporum ovale), is involved,[11][12] as well as genetic, environmental, hormonal, and immune-system factors.[13][14] A suggestion that seborrhoeic dermatitis is an inflammatory response to this yeast has yet to be proven.[15] Those afflicted with seborrhoeic dermatitis have an unfavourable epidermic response to the infection, with the skin becoming inflamed and flaking.

In children, excessive vitamin A intake can cause seborrhoeic dermatitis.[16] Lack of biotin,[17] pyridoxine (vitamin B6)[17][18] and riboflavin (vitamin B2)[17] may also be a cause.

Differentiating Seborrheic dermatitis from Other Diseases

Differential diagnosis of seborrheic dermatitis can be classified into two types by age group[19]

Differential diagnosis in infants

Differential diagnosis in Adults

Epidemiology and Demographics

Risk Factors

Most common risk factors for Seborrheic dermatitis are[21][22]

Other risk factors include

  • Stress[26]
  • Patients treated with psoralene and ultravoilet light A for psoriasis are seen to have a predisposition for seborrheic dermatitis.
  • Male population is more prone to develop seborrheic dermatitis as compared to females.[27]
  • Obesity, Diabetes Mellitus and other endocrine disorders causing alteration in glucose metabolism.[28]
  • Seasonal changes such as low temperature and decreased humditiy may have a significant role in seborrheic dermatitis flare ups[29]
  • Drugs such as haloperidol deconate, lithium and chlorpromazine are associated with increased risk of disease in some patients.

Screening

Natural History, Complications, and Prognosis

Natural History

Complications

Side effects to inflammation may include temporary hair loss. If severe outbreaks go untreated for long periods of time, permanent hair loss may result due to damaged hair follicles.

Prognosis

Diagnosis

Diagnostic Criteria

There are no definitive diagnostic criteria for seborrheic dermatitis.

History and Symptoms

Obtaining complete history of seborrheic dermatitis 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

Physical Examination

Head

Ear

Neck

Trunk

Extremities

Genitals

Medical Therapy

  • Seborrheic dermatitis[30]
  • 1. Antifungal agents
  • 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
  • 2. Corticosteroids
  • 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
  • 3. Lithium salts

Plant-based treatments

The World Health Organization mentions Aloe vera gel as a yet to be scientifically proven traditional medicine treatment for Seborrhoeic dermatitis.[31]

Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Prevention

Related Chapter

External Links

References

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  3. Dessinioti, Clio, and Andreas Katsambas. "Seborrheic dermatitis: Etiology, risk factors, and treatments:: Facts and controversies." Clinics in dermatology 31.4 (2013): 343-351.
  4. ===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.
  5. Soares RC, Zani MB, Arruda AC, Arruda LH, Paulino LC (2015). "Malassezia intra-specific diversity and potentially new species in the skin microbiota from Brazilian healthy subjects and seborrheic dermatitis patients". PLoS One. 10 (2): e0117921. doi:10.1371/journal.pone.0117921. PMC 4335070. PMID 25695430.
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