Seborrheic dermatitis of adults L21.9

Plenary 1776; Unna 1886

Common, genetically predisposed, chronic dermatitis affecting the seborrheic zones, frequently recurrent, otherwise relatively mild with a seasonal course (improvement in the summer months), the independence and etiology of which are disputed.

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.

It is assumed that the disease is based on a genetic predisposition, whereby various external and internal influences (e.g. microbial colonization, climate, stress) can lead to the outbreak.

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

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

In case of a dysfunction of the sebaceous glands, on the one hand 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 in 1874 by Louis-Charles Malassez, after whom Malassezia spp. are named. Versch. Investigations suggest this assumption for the infantile as well as for the adult type. However, other studies found no difference in scalp colonization between affected and unaffected individuals.

Seborrheic dermatitis occurs more frequently in HIV-infected individuals (30% of HIV patients with LAS (=lymphadenopathy syndrome) develop seborrheic dermatitis). Parkinson's disease also aggravates the disease.

In many countries there is a seasonal dependence of the disease with a peak in winter.

• Type I: Occurring in infancy, manifestation in the first 3 months of life. The clinical course is self-limiting.
• Type II: Occurring during the 3rd-5th decade of life, (phases of high sebaceous gland activity); males are clearly more frequently affected than females. A genetic disposition has not been described. Dry form of capillitium infestation especially beyond the 5th decade of life in the senium.
• In case of infestation of the capillitium more often sleep-deprived and stress-triggered.

Extensive, acute forms of seborrhoeic dermatitis should lead to the suspicion of a predisposing HIV-infection.

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.

The clinical picture of seborrheic dermatitis varies according to the location:

Capillitium: The capillitium is preferentially affected. It is characterized by few sharply defined, extensive redness (which may also be completely absent) with dense, non-adherent white scaling of the head (dandruff). The hairline borders are usually not exceeded (DD: psoriasis capitis, in which this border is usually exceeded). Itching is absent or only mild. Not infrequently, seborrheic dermatitis of the capillitium is accompanied by a presumably "inflammation-related" effluvium, which may be reversible under sufficient therapy.

The mildest form ofseborrhoeic dermatitis with discrete erythema and fine scaling which not infrequently occurs with seborrhoea is called"seborrhoeiceczematid".

Face: The centrofacial "seborrheic skin areas" such as mid-forehead, perinasal region are affected with red, marginal, scaly plaques with varying degrees of scaling. In some patients, preferably young women, a scaly erythema is found only paranasally(erythema paranasale). The course is highly chronic (Bieber T 2018).

Eyelids: The eyelids may be affected as part of a generalized seborrheic dermatitis. However, the eyelid affection may also manifest as a monotopic course(blepharitis chronica eczematosa). Experience has shown that it is resistant to therapy and extremely persistent, especially since a long-term therapy with corticosteroids has usually preceded the visit to the specialist (see also eyelid dermatitis).

Trunk: Here, the central seborrhoeic zones (sweat grooves in the sternal area, along the spine, shoulder girdle) are affected. Figure-like, little or not at all pruritic, scaling of varying intensity, usually localized, sharply demarcated, red or red-brown patches, papules or confluent plaques are seen.

Some skin lesions appear marginal and are then difficult to differentiate differentially from tinea corporis or (seborrhoidal) psoriasis vulgaris.

Pityriasiform seborrhoid: Very rarely, a truncal exanthematous acute or subacute course reminiscent of pityriasis rosea is observed. In contrast to pityriasis rosea, the primary plaque and a distinct collerette scaling are absent (Bieber T 2018).

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

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:

• Differentiation from other forms of eczema (e.g. atopic eczema, allergic dermatitis) and from psoriasis.
• Tinea faciei: microscopic and cell culture fungus detection!
• Tinea corporis: microscopic and cell culture fungus detection!

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

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.

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.

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

In case of moderate to severe infestation, antimycotic preparations containing azole derivatives such as ketoconazole ( Ket-Dandruff Shampoo), clotrimazole (SD-Hermal Minute Cream) or ciclopirox (e.g. Batrafen S Shampoo) or salicylic acid (Stieproxal) have proven effective.

Alternative: Tar-containing preparations such as LCD 5% in Lygal head ointment or Ichthyol® -containing preparations such as Ichthosin cream or Ichthoderm cream.

Alternatively: Zinc pyrithione or selenium disulphide containing shampoos such as Desquaman® may be helpful.

In case of a strong inflammatory component, topical glucocorticoids (e.g. Pandel cream, Ecural fat ointment or solution) may be used for a short time (!). Possibly combination preparations of glucocorticoids with added tar (e.g. Alpicort), keratolytically acting preparations with salicylic acid (e.g. Liquor carbonis detergens/Salicylic Acid Head Ointment ) or desquamating shampoos like Criniton® Hair Wash.

Facial foci: Antifungal agents such as creams containing ketoconazole or ciclopirox (e.g., Nizoral cream; Batrafen cream) are successful. Do not use ointment bases that are too oily!

Alternatively, 1-2% metronidazole creams(e.g. Metrocreme, R167 ) or gels (e.g. Metrogel).

Supplementary: In case of exacerbation, short-term (!) glucocorticoid creams such as 1% hydrocortisone buteprate or 0.05% betamethasone V lotio R030.

In seborrhoeic blepharitis: glucocorticoid-containing eye ointment (e.g. Ficortril). Good treatment results have been reported with lithium (8% lithium gluconate cream) and tacrolimus (Protopic ointment)/pimecrolimus (Elidel) therapy.

Body foci: antifungal agents such as creams containing ketoconazole (e.g. Nizoral cream). Again, no ointment bases that are too oily! Sometimes 2% clioquinol lotion R050 is also helpful, lithium-containing ointments (e.g. Efadermin) on a trial basis. Glucocorticoid creams ( glucocorticoids , topical) for a short time (!) only in case of exacerbation.

Skin cleansing: For skin cleansing alkali-free detergents (e.g. Eucerin), bath additives such as wheat bran-oat straw extract (e.g. Silvapin).

Supplementary: A mild UV therapy can be tried, but it does not lead to success in all cases. Slow dose increase is recommended; UV-induced irritations are possible.

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.

Order therapy:

Fatty externals should be strictly avoided, rather drying but moisturizing externals are indicated.

A balanced lifestyle, avoidance of "stress" can also help to improve the excessive sebum production. Nutritional therapy: whole food diet with fresh fruits and vegetables.

Hydrotherapy: dehydration with oak bark extract as a poultice or O/W emulsion (e.g. Tannolact®-(cream/Lotio): contains as active ingredient a synthetic tannin "a sulfonated phenol-methanal-urea polycondensate).

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

Phytotherapy:

Mahonia (Mahonia aquifolium) has antiphlogistic, antiproliferative, antibacterial, antiseborrheic and keratolytic effects. All components of the plant (root bark, stems, leaves) are used. As 10% mother tincture, available as Rubisan® ointment N/cream 2-3 x / day can alleviate eczema.

Cardiospermum halicacabum (balloon vine) extracts have an antiphlogistic effect due to their content of saponins, alkaloids, flavonoids and tannins, which has proven useful in seborrheic 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 proven effective in reducing the fat content.

Pansy herb-as a tea infusion has an antiphlogistic effect, see also Violae herba cum flore.

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