Seborrheic dermatitis of adults L21.9

Author: Prof. Dr. med. Peter Altmeyer

All authors of this article

Last updated on: 11.04.2021

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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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It is assumed that the disease is based on a genetic predisposition (androgenic hair loss, Parkinson's disease, HIV infections), whereby various external and internal influences (e.g. microbial colonization, climate, stress) can lead to the onset.

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 respectively the initiation or the influence of the resident flora of the skin in particular by Malassezia spp (in particular Malassezia globosa) is discussed.

This still controversial etiopathogenetic connection was already suspected in 1874 by Louis-Charles Malassez, after whom the Malassezia spp. are named. Versch. Investigations suggest this assumption with the infantile as well as with the adult type. Other studies, however, found no difference in scalp colonization between affected and unaffected individuals.

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

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

Manifestation
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  • 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.

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, 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.

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

Scalp foci

Complex ointments/gels/shampoos/solutions

Ketoconazole

Ket Shampoo

Ciclopiroxolamine

Batrafen shampoo, Sebiprox solution

Salicylic acid

Criniton, Squamasol

Zinc Pyrithione

Desquaman

Selenium sulfide

Selsun, Selukos

Sulphur

Diasporal

Coal tar

Tarmed

Without additive

Dermowas, Physiogel

Creams/ointments/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 herbs

Tinctures/gels/solutions/creams/lotions

Ketoconazole

Nizoral, Terzolin

Metronidazole gel

Metro Gel

Metronidazole Cream

Metro Cream

Erythromycin solution

Aknemycin

Erythromycin gel

Eryacne 2-4%

Salicylic acid ethanol gel

Ethanol-containing salicylic acid gel 6% (NRF 11.54.)

Salicylic acid, Na-bituminosulfonate

Aknichthol Soft Lotio

Body lotions

Creams/Ointments

Ketoconazole Cream

Nizoral Cream

Ciclopiroxolamine Cream

Batrafen Cream

Metronidazole cream

Metro Cream

Erythromycin cream

Aknemycin cream

Lithium ointment

Efadermin ointment

Clotrimazole cream

SD-Hermal Minute Cream

Lotions

Clioquinol lotion (if necessary additionally ichthyol, sulphur)

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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