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Seborrheic Dermatitis
Diagnosis/Definition
- Chronic superficial inflammatory disease of the skin.
- Predilection for the scalp, eyebrows, nasolabial creases, ears, sternal area, groin and gluteal crease.
- Characterized by scant, loose, dry, moist or greasy scales and by crusted, pink or yellow patches of various shapes and sizes; by remissions and exacerbations; and more or less by itching.
- On patients with darker skin tone, lesions may have a gunmetal color, and may be annular or arcuate.
- On the scalp manifests as dry powdery dandruff or an oily type with erythema and thick crusts. Frequently spreads beyond the hairy scalp.
- On and in the ears, seborrheic dermatitis is frequently mistaken for otitis externa. There is scaling in the external ear canals, around the auditory meatus and in the postauricular region or under the lobe. In these areas the skin often becomes red, fissured and swollen giving the appearance of an infection.
Initial Diagnosis and Management
- Evaluation: A focused history and physical examination. Areas to be examined should include the scalp, ears and mid-face.
- Emphasize that this is a chronic disorder with no cure but with several good forms of treatment which can control symptoms. Document education and provide handout or brochure (American Academy of Dermatology website is: www.aad.org).
- The scalp should be shampooed several times per week. Selenium sulfide (Selsun or Exsel lotions), tar, zinc pyrithionate and resorcin shampoos are all excellent. Stress that shampoo should be left on the scalp for 3 to 10 minutes (to allow penetration) prior to rinsing.
- Corticosteroid solutions such as Synalar, Fluonid and Valisone (betamethasone 17-valerate) lotion applied BID to the scalp are effective and may be necessary to improve seborrheic dermatitis to a maintenance level. Luxiq (betamethasone valcarate) and Olux (Clobetaso) foams are also useful, bus some patients complain of irritation due to the foam itself.
- Ear involvement may be treated with low potency topical steroid creams. Tridesilon Otic Lotion (0.5 percent desonide and 2 percent acetic acid) is also effective.
- On glabrous skin (such as the thin skin of the forehead) non-fluorinated topical steroid preparations are adequate (hydrocortisone 1%, Desonide, Westcort, etc.).
- Topical steroids should not be used for blepharitis, as steroid preparations used in this area may induce glaucoma and cataracts. Gently cleansing the eyelid skin with Johnson’s baby shampoo or Cetaphil may be beneficial.
Ongoing Management and Objectives
Major objective is symptom relief as this is a chronic disorder with intermittent exacerbations and maintained clearance rather than “a cure” is the reasonable objective.
Indications for Specialty Care Referral
Signs and symptoms that bring into question the correct diagnosis (i.e., petechiae, severe oozing or crusting, significant alopecia, severe or resistant symptoms).
Criteria for Return to Primary Care
Completed Dermatology evaluation which confirms the diagnosis and appropriate management of seborrheic dermatitis or any other diagnosis which may be managed at the primary care level.
