Seborrheic dermatitis

Seborrheic dermatitis
Chronic papulosquamous condition
Occur on sebum-rich area of scalp, face and
trunk
Occur as an isolated condition or in
conjunction with other disorder such as
blepharitis, acne vulgaris, ocular rosacea
Varies from mild dandruff to exfoliative
erythroderma
Seborrheic dermatitis (cont.)
Aggravated by change in humidity,
change in season, trauma (e.g.
scratching) or emotional stress
Associated with several systemic
disease include AIDS, zinc deficiency,
Parkinson disease
Frequently seen in patient who
received psoralen with UVA therapy
Causative factor
Malassezia globosa
Sebum production
Genetic susceptibility for inflammatory
response
Malassezia and seborrheic
dermatitis
Lipophilic yeast
Found in normal skin
Research document supported relation
between Malassezia and seborrheic
dermatitis
:clinical response to antifungal drug
:increase in number of Malassezia in
recurrence disease
Causes
Malassezia are not the cause but are a cofactor
link to T-cell depression, increase sebum level
and activation of the alternative complement
pathway
Skin barrier dysfunction prone to disease
Medication that induced flare up : auranofin,
aurothioglucose, buspirone, chlorpromazine,
cimetidine, ethionamide, gold, griseofulvin,
haloperidol, interferon Alfa, lithium, methoxsalen,
methyldopa, phenothiazines, psoralens,
stanozolol, thiothixene and trioxsalen

Epidemiology
Occurrence 1-3%
Variable age range include infant
through adult
Increase rate of occurrence in infant
and 4-5
th
decade of life
Male > female
African-American > Caucasian
Epidemiology (cont.)
34-83% found in AIDS
Higher rate of occurrence in DM,
obesity, malabsorption, Parkinson
disease, epilepsy
Etiology
Unclear
Sebum and lipid level
:increase sebum and lipid level in
Parkinson disease, African-American >
Caucasian
:large and active sebaceous gland in
newborn infant
Etiology (cont.)
Immunologic response
:depress T-cell function lead to
increase Malassezia growth
:increase natural killer cell activation
:increase inflammatory interleukin
Medication induced :found in
Parkinson treated with specific
neuroepileptic drug
Clinical
Depend on age, skin type, presence or
absence of concurrent systemic illness
Dry and flaky with white scale or
greasy with crusting
Skin type 4-6
:reduce visible erythema
:hypo or hyperpigmented
Clinical (cont.)
Increase in winter and early spring
Remission commonly in summer
Clinical finding in newborn
infant
Scale located throughout the scalp but
also on face, chest, groin, neck, ears
and eyelid
Cradle cap and napkin dermatitis
appearance
Related to sebum overproduction
Clinical finding in newborn
infant (cont.)
Severe generalized seborrheic
dermatitis may represent Leiner
disease (exfoliative disorder with
anemia, diarrhea, immunodeficiency,
concomitants bacterial and candidial
infection
Clinical finding in adult
Involved scalp, face, chest, axillae,
submammary area, groin, gluteal
region
Scalp and face involvement
:most prominent around eyebrows,
perinasal skin, postauricular area,
ears, eyelids
Clinical finding in adult
(cont.)
:may extend from frontal scalp onto
upper forehead
Perinasal and post auricular skin can
appear either hypopigmented,
hyperpigmented, erythematous
Crusting may be seen in inner ear and
ear canal
Clinical finding in adult
(cont.)
Chest, axillae, groin, gluteal
involvement is usually scaly with
hypopigmentation or erythema
beneath the scale
Occasionally bacterial superinfection
Clinical finding in
immunocompromise
Similar to normal adult but more
extensive
More visible inflamed skin
Involvement include blepharitis,
Meibomian gland occlusion result in
scaling and burning of eyelids
Diffuse lesion at axillae, extremities
and groin
Clinical finding in
immunocompromise (cont.)
Generalized seborrheic erythroderma
is rare but more often
May presented bacterial, candidial,
dermatophyte superinfection
Moist and extreme erythema plaques
at torso and extremities
Histopathology
Spongiotic dermatitis
Marked spongiosis, acanthosis,
hyperkeratosis
Classic finding :parakeratosis,
neutrophilic infiltrate, scale crust at the
opening of infundibulum of hair follicle,
psoriasiform hyperplasia of epidermis
Histopathology (cont.)
Some degree of epidermal rete ridge
elongation
In immunocompromise : superficial
perivascular infiltration with plasma cell
and neutrophils, leukocytoclasia,
keratinocyte necrosis within epidermis

Histology of seborrheic
dermatitis
Perifollicular
parakeratosis rim in
seborrheic
dermatitis
Differential diagnosis in
children
Contact dermatitis
Atopic dermatitis
Tinea capitis/ faceii
Candidiasis
Multiple
carboxylase
deficiency
Biotin responsive
dermatitis
Scabies
Impetigo
Psoriasis

Differential diagnosis in
adult
Psoriasis
Pityriasis rosea
Contact dermatitis
SLE
Atopic dermatitis

Candidiasis
Rosacea
Impetigo
Tinea versicolor
Sarcoidosis

Treatment
Early treatment
Behavior modification to reduce
excoriation
Avoid shampoo and topical product
that dry the hair and skin

Treatment (cont.)
Steroid
:low and middle potency
:may increase recurrence rate
:rebound effect
:discourage except for short term use

Treatment (cont.)
Antifungal drug
:ketoconazole
:ciclopiroxolamine
:selenium sulfide

Treatment (cont.)
Other ingredients
:zinc pyrithione
:coal tar
:salicylic acid
:sodium sulfacetamide
:olive oil or mineral oil compresses
with warm water

Treatment (cont.)
:lithium succinate
Topical immunomodulator
:topical tacrolimus and pimecrolimus
:antifungal activity
:FDA not currently approved
:avoid side effect associated with
topical corticosteroid
Clinical study of topical
immunomodulator
70% or greater clearance after 1%
tacrolimus ointment in seborrheic dermatitis
A double-blind, vehicle controlled 4 wks. trial
randomized patients with seborrheic
dermatitis
:1% pimecrolimus effective and well
tolerated for moderate to severe facial
seborrheic dermatitis
:efficacy as early as 2 wks.
Clinical study of topical
immunomodulator (cont.)
Open-label pilot trial in 5 African-
American seborrheic dermatitis
patients with hypopigmentation
:1% pimecrolimus cream for 16 wks.
:marked decrease severity
:improve hypopigmentation
Clinical study of topical
immunomodulator (cont.)
Open-label pilot trial of seborrheic
dermatitis in 5 African-American with
associated hypopigmentation
:1% pimecrolimus cream for 16 wks.
:marked decrease severity of disease
:improved hypopigmentation
Treatment (cont.)
Narrow band UVB phototherapy
:18 patients was given treatment 3 time/wk
until complete clearing or max. 8 wks.
:6 complete clearance and 12 marked
improved
:relapse all patients after average 3 wk.
:safe and effective in severe seborrheic
dermatitis
Seborrheic dermatitis and
biotin
Breast milk is deficient in biotin than
cows milk and aggravated by poor
maternal nutrition
4 extensive seborrheic dermatitis infant
(Leiners disease)
Dramatically improve after biotin
injection in nursing mother