Seborrheic dermatitis of adults L21.9

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Dermatitis dysseborrhoic; Dermatitis seborrhoic; Eczema seborrhoic; seborrheic dermatitis; Seborrheic dermatitis; seborrheic eczema; Seborrheic eczema of the adult; Seborrheic scalp eczema; seborrhoidal dermatitis; Unna's disease

History
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Plenary 1776; Unna 1886

Definition
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Frequent, genetically predisposed, chronic, therapy-resistant, otherwise relatively mild dermatitis affecting the seborrhoeic zones, with a seasonal course (improvement in the summer months), whose autonomy and aetiology is disputed.

Occurrence/Epidemiology
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Prevalence (Central Europe): 3-10% of the population.

Considering the wide spectrum of seborrheic dermatitis, including the symptoms in infancy, almost everyone has experienced this disease at some time or another.

Etiopathogenesis
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The nosological position has been disputed since the first description by Josef Jakob Plenk.

Unna described a "chronic parasitic skin inflammation characterized by abnormal fat content of the most superficial epidermal layers".

In case of a dysfunction of the sebaceous glands, a minus variant of psoriasis or the initiation or the influence of the resident flora of the skin especially by Malassezia spp (especially Malassezia globosa) is discussed.

This still controversial etiopathogenetic connection was already suspected by Louis-Charles Malassez in 1874 after whom the Malassezia spp. are named. Versch. Studies suggest this assumption for both the infantile and the adult type. Other studies, however, found no difference in the colonization of the scalp between affected and non-affected persons.

The seborrhoeic dermatitis occurs more frequently in HIV-infected persons. Parkinson's disease also has a worsening effect.

In many countries, the disease is seasonally dependent, with a peak of the disease in winter.

Manifestation
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  • Type I: Occurs in infancy, manifestation in the first 3 months of life. The clinical course is self-limiting.
  • Type II: Occurs during the 3rd to 5th decade of life, (phases of high sebaceous gland activity); men are significantly more frequently affected than women. A genetic disposition is not described. Dry form of the capillitium infestation especially also beyond the 5th decade of life in the senium.
  • In case of infestation of the capillitium more frequent sleep deficiency and stress-triggered.

Extensive, acute forms of seborrhoeic dermatitis should consider a predisposing HIV infection.

Localization
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Seborrheic zones: face (eyebrows, nasolabial, retroauricular), often on the capillitium.

Other localizations: Beard area, intertriginous, pre-sternal, occasionally genital (especially in men), on the back.

Clinical features
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The clinical picture of seborrheic dermatitis varies from place to place:

Capillitium: Preferably the capillitium is affected. It is characterized by a little sharply defined, flat redness (this can also be completely absent) with dense, non-sticky, white dandruff. The boundaries of the hairline are usually not exceeded (DD: Psoriasis capitis, where this limit is usually exceeded). Itching is absent or only slightly pronounced. Frequently, seborrhoeic dermatitis of the capillitium is accompanied by a presumably "inflammation-related" effluvium, which can be reversible with sufficient therapy.

The"seborrhoeic eczematide" is the mildest form of seborrhoeic dermatitis with discrete erythema and fine scaling, which often occurs with seborrhoea.

Face: Affected are the centrofacial "seborrhoeic skin areas" such as the middle of the forehead, perinasal region with red, marginalized, scaly plaques with different levels of scaling. In some patients, preferably in young women, scaly erythema(erythema paranasale) is found only paranasal. The course is highly chronic (Bieber T 2018).

Eyelids: The eyelids may be affected in the context of generalized seborrheic dermatitis. However, the eyelid infestation can also manifest itself as a monotopic form(Blepharitis chronica eczematosa). Experience has shown that it is resistant to therapy and eminently persistent, especially since a long-term therapy with a corticosteroid externum usually precedes the visit to the specialist (see also eyelid dermatitis).

Trunk: Here the central seborrheic zones (sweat ducts in the sternal area, along the spine, shoulder girdle) are affected. It is characterized by figured, little or no itching, scaling of varying intensity, mostly localized, sharply defined, red or red-brown spots, papules or confluent plaques.

Some skin lesions appear marginal and are then hardly distinguishable from tinea corporis or (seborrhoid) psoriasis vulgaris.

Pityriasiformes seborrhoid: Very rarely a truncated exanthematic acute or subacute form is observed which resembles a pityriasis rosea. In contrast to Pityriasis rosea the primary plaque and a distinct Collerette scaling is missing (Bieber T 2018).

Histology
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The histological picture is not specific for "seborrheic dermatitis". Usually, an acanthotic widened epidermis of varying intensity is found with orthohyperkeratosis and focal parahyperkeratosis (parakeratosis mound). Frequent loss of the basket plexus structure. In the papillary dermis a rather minor edema is visible. Bulky, perivascularly oriented, but also diffuse predominantly lymphocytic infiltrate. Focal epidermotropia with mild (also absent) cancellous bone disease.

Profile:

  • psoriasiform epidermihyperplasia
  • low grade spongiosis with emphasis on the infundibula
  • low superficial superficial perivascular lymphocyte inflite rate
  • Parakeratosis mound

Differential diagnosis
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Depending on the pattern of infestation and localisation, different diseases are possible:

capillitium:

  • Tinea capitis: microscopic and cell culture fungus detection!
  • Lichen simplex of the neck (especially in women): localised, very itchy, clearly infiltrated form of eczema.
  • Atopic scalp eczema: detection of further signs of atopy; diffuse, dry and small lamellar scaling, very itchy eczema.
  • Pediculosis capitis: acute, mostly weeping, massively itchy dermatitis. Detection of lice (nits).
  • Contact allergic eczema of the scalp: e.g. after application of hair dyes.
  • Lichen planus follicularis capillitii: eminently chronic, often itchy, rather localised clinical picture with follicular inflammation and alopecia. Typical are peripilary scaling, distally separating the hair shaft with the image of "lonely hairs".
  • Pemphigus foliaceus: rare! highly inflammatory, erosive weeping; involvement of other seborrhoeic zones. Histological/immunohistological clarification.

With other localizations:

Notice! The absence of itching in seborrheic dermatitis helps in the differential diagnosis.

Complication(s)
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Seborrheic erythroderma: is one of the most common causes of erythroderma. In most cases, this universal integumentary affection is predisposed to a generalized seborrheic dermatitis (Bieber T 2018). This infestation pattern must be distinguished from a Sézary syndrome.

General therapy
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Because of the tendency to recur, the treatment of seborrhoeic eczema should always be considered as a "long-term strategy". Here, the focus is on correcting the existing seborrhoea and/or the microbial malcolonisation. The treatment principle is anti-inflammatory and antimicrobial. Due to a possible irritability of this dermatosis, aggressive treatment methods should not be applied. Treatment of infant eczema: see below Dermatitis seborrhoides infantum.

External therapy
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Capillitium: In case of light infestation, rather drying shampoos like Dermowas, mineral salt shampoos or Sebamed liquid.

In case of medium to severe infestation, antimycotic preparations with azole derivatives such as ketoconazole (ket scale shampoo), clotrimazole (SD-Hermal Minute Cream) or ciclopirox (e.g. Batrafen S Shampoo) or salicylic acid (Stieproxal) have proved successful.

Alternative: Tar-containing preparations such as LCD 5% in Lygal Ointment or Ichthyol® -containing preparations such as Ichthosin Cream or Ichthoderm Cream.

Alternatively, shampoos containing zinc pyrithione or selenium disulphide such as Desquaman® may be helpful.

In the case of highly inflammatory components, topical glucocorticoids (e.g. pandulum cream, ecural ointment or solution) can also be used for a short time (!). Possibly combination preparations of glucocorticoids with tar (e.g. Alpicort), keratolytic preparations with salicylic acid (e.g. Liquor carbonis detergens/Salicylic acid ointment ) or scaling shampoos like Criniton® hair wash.

Facial foci: Successful are antimycotics like creams containing ketoconazole or ciclopirox (e.g. Nizoral cream; Batrafen cream). No oily ointment bases that are too greasy!

Alternatively, 1-2% metronidazole creams(e.g. Metrocreme, R167 ) or gels (e.g. Metrogel), antibiotic-containing topicals such as 1-2% erythromycin cream (acne mycin) or solution (e.g. Stiemycin solution, R086 ) can be used.

Supplementary: In case of exacerbation short term (!) glucocorticoid creams like 1% hydrocortisone buteprate or 0,05% betamethasone-V Lotio R030.

For seborrhoeic blepharitis: Glucocorticoid-containing eye ointment (e.g. Ficortril). Good treatment results were reported with a therapy with lithium (8% lithium gluconate cream) and tacrolimus (protopic ointment)/pimecrolimus (Elidel).

Body foci: Antimycotics such as creams containing ketoconazole (e.g. Nizoral cream). Also here no ointment bases that are too fatty! Sometimes 2% Clioquinol-Lotion R050 is also helpful, and ointments containing lithium (e.g. Efadermin) have been tried. Only in case of short-term (!) exacerbation glucocorticoid creams ( glucocorticoids, topical).

Skin cleansing: For skin cleansing alkali-free detergents (e.g. Eucerin), bath additives like wheat bran-oatstraw extract (e.g. Silvapin).

Supplementary: A mild UV therapy can be tried, but it does not always lead to success. Slowly increasing the dose is recommended; UV-induced irritations are possible.

Internal therapy
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For disseminated forms, internal therapy with glucocorticoids in medium dosages such as prednisolone (e.g. Decortin H). In case of multiple relapses, trial with tetracycline (Tetracycline Wolff Kps.) 1 g/day p.o. in week 1, 0.5 g/day p.o. in week 2 and 0.25 g/day p.o. in week 3.

Progression/forecast
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The chronic recurrent course of the disease is typical, with worsening in the winter months and often complete healing under summery, maritime climates. Thrust activities are frequently observed under beta-blocker medication (frequent constellation). Basically, the following applies: the disease can be significantly improved but not cured.

Naturopathy
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Order Therapy:

Fats are to be strictly avoided, but dehydrating but moisturizing topicals are indicated.

A balanced lifestyle, avoiding "stress" can also help to improve excessive sebum production.

Hydrotherapy: desiccation with oak bark extract as compress or O/W emulsion (e.g. Tannolact®-(cream/lotio): contains as active ingredient a synthetic tanning agent "a sulfonated phenol-methanal-urea-polycondensate)

Washings with fragrance-free shower gels with dead sea salt have a disinfecting and drying effect.

phytotherapy:

Mahonia (Mahonia aquifolium) has antiphlogistic, antiproliferative, antibacterial, antiseborrheic and keratolytic effects. It uses all the components of the plant (root bark, stem, leaves). As a 10 % mother tincture, available as Rubisan Ointment N/Creme 2-3 x / day can reduce eczema.

Cardiospermum halicacabum (balloon vine) extracts have an anti-inflammatory effect due to their content of saponins, alkaloids, flavonoids and tannins, which has been shown to be beneficial in seborrhoeic eczema. Commercially available are Cardiospermum-halicacabum leaf extracts (e.g. Dermaplant® ointment, Halicar® ointment).

Astringent compresses, e.g. with oak bark extracts or black tea (alternatively green tea), have proved effective in reducing the fat content.

Tables
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Localization

Vehicle

Active ingredients

Example preparations

Head Herd

Complex ointments/gels/shampoos/solutions

Ketoconazole

Ket Shampoo

Ciclopiroxolamine

Batrafen Shampoo, Sebiprox solution

Salicylic acid

Criniton, Squamasol

Zinc pyrithione

Desquaman

Selenium sulphide

Selsun, Selukos

Sulphur

Diasporal

Coal tar

Tarmed

Without additive

Dermowas, Physiogel

Creams/Salves/Tinctures

Salicylic acid

Squamasol, Lygal head ointment

Glucocorticoids

Ecural, Dermatop

Prednisolone

Lygal Head Tincture

Prednisolone, salicylic acid

Alpicort solution

Creams

Ammonium bituminosulfonate

Ichthosin, Ichthoderm,

133

Facial foci

Tinctures/gels/solutions/creams/lotions

Ketoconazole

Nizoral, Terzolin

Metronidazole gel

Metro Gel

Metronidazole cream

Metro Cream

Erythromycin solution

Aknemycin

Erythromycin gel

Eryacnene 2-4

Salicylic acid ethanol gel

Salicylic acid gel containing ethanol 6% (NRF 11.54.) 216

Salicylic acid, Na-bituminosulfonate

Aknichthol Soft Lotio

Body herd

Creams / Ointments

Ketoconazole cream

Nizoral Cream

Ciclopiroxolamine cream

Batrafen Cream

Metronidazole cream

Metro Cream

Erythromycin Ointment

Aknemycin cream

Lithium Ointment

Efadermin ointment

Clotrimazole cream

SD-Hermal Minute Cream

Lotions

Clioquinol lotion (if necessary additionally ichthyol, sulphur)

050

Bath additives

Wheat bran- oat straw extract

Silvapin

without special additives

Dermowas, Satina, Sebamed

Note(s)
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Inform the patient about possible worsening of the skin condition due to excessive alcohol consumption, consumption of fatty or strongly spiced food.

Literature
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  1. Barac A et al (2015) Presence, species distribution, and density of Malassezia yeast in patients with seborrhoeic dermatitis - a community-based case-control study and review of literature. Mycoses 58: 69-75
  2. Bieber T (2018) Other forms of dermatitis. In: Braun-Falco`s Dermatology, Venerology Allergology G. Plewig et al (Hrsg) Springer Verlag S 571-576

  3. Borda LJet al (2015) Seborrheic Dermatitis and Dandruff: A Comprehensive Review. J Clin Investig Dermatol 3:2.
  4. Braza TJ et al (2003) Tacrolimus 0.1% ointment for seborrheic dermatitis: an open-label pilot study. Br J Dermatol 148: 1242-1244
  5. Dreno B et al (2003) THE STUDY INVESTIGATOR GROUP. Lithium gluconate 8% vs ketoconazole 2% in the treatment of seborrhoeic dermatitis: a multicentre, randomized study. Br J Dermatol 148: 1230-1236
  6. Faergemann J (2001) Treatment of seborrhoeic dermatitis with oral terbinafine? Lancet 358: 170
  7. Moises-Alfaro CB et al (2002) Are infantile seborrheic and atopic dermatitis clinical variants of the same disease? Int J Dermatol 41: 349-351
  8. Moraes AP de et al (2007) An open-label efficacy pilot study with pimecrolimus cream 1% in adults with facial seborrhoic dermatitis infected with HIV. JEAV 21: 596-601
  9. Ooi ET et al (2014) Improving the management of seborrhoeic dermatitis. Practitioner 258:23-26
  10. Okokon EO et al (2015) Topical antifungals for seborrhoeic dermatitis. Cochrane Database Syst Rev 5 PubMed PMID: 25933684.
  11. Plenck JJ (1776) Doctrine de morbis cutaneis. Rodolphum Graeffer, Vienna
  12. Ramos-E-Silva M et al (2014) Red face revisited: Endogenous dermatitis in the form of atopic dermatitis and seborrheic dermatitis. Clin Dermatol 32:109-115
  13. Sticherling M (2017) Psoriasis capitis and seborrheic eczema of the scalp. Dermatologist 68: 457-468
  14. Unna PG (1886) The seborrheic eczema. Monthly journals for practical dermatology 6: 829-846
  15. Warshaw EM et al (2007) Results of a randomized, double-blind, vehicle controlled efficacy trial of pimecrolimus cream 1% for the treatment of moderate to severe facial seborrheic dermatitis. J Am Acad Dermatol 57: 257-264.
  16. Wilsmann-Theis D et al (2014) Psoriasis and eczema on the capillitium. Dermatologist 65: 1043-1049

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