Last update: September, 2014

What is Seborrheic Dermatitis?

In simple terms, SD is a fairly common inflammatory skin condition that affects between 3% to 5% of the overall population [89]. It's usually seen in areas of the skin that are rich in sebaceous glands and sebum, including the scalp, face, eyebrows, beard, nose, ears, neck, chest, navel, armpits, groin, and perianal area. The usual signs of SD are areas of pink to red inflamed skin with either dry or greasy flakes. In some cases, the affected areas may also itch or burn. Try this Yahoo image search to see photos of SD. Here are Google image searches as well: one two.

Researchers and physicians don't know the exact causes of SD. One popular theory is that SD is associated with yeast (malassezia genus) organisms that are common residents of human skin [21],[25],[47],[74]. Since they need lipids to survive [100], they tend to colonize areas of the skin that are relatively rich with sebum. These fungi, according to some studies, are believed to trigger an immuno-allergic type response in susceptible individuals [8],[50],[51],[83], while other studies report that the yeast metabolize sebum and generate byproducts that are irritating to the skin [11],[23],[68],[74].

Other factors suspected of possibly contributing to SD include:

*   genetic predisposition [10]
*   seborrhea (oily skin) fosters the growth of malassezia [11],[17],[23],[68],[74]
*   environment, i.e., temperature, humidity [10]
*   exposure to soaps, detergents and irritants that degrade the skin's barrier function [18]
*   androgens may play a role by increasing sebum output [64],[88]
*   Parkinson's disease [42]
*   other neurological conditions such as stroke, multiple sclerosis, and paralysis [17]
*   HIV infection [42],[55],[59]
*   mood disorders such as depression [58],[69]
*   alcoholism [53],[67],[85]
*   stress [10]
*   malnutrition [33],[69],[46],[80],[119]
*   poor hygiene [17]
*   seasons, i.e., winter, summer [10]
*   work environment [10]

To sum it all up, it seems that there are a variety of possible factors that might contribute to the development of seborrheic dermatitis. Unfortunately, researchers don't have a full understanding of these factors and their relationship to SD. In light of all the research that has been conducted, however, it does appear that there are three main factors that are believed to play a major role in SD: malassezia yeast, sebum, and individual sensitivity to the yeast. [10],[23]

How is Seborrheic Dermatitis Treated?

There are many treatments available to manage seborrheic dermatitis. The aim of most of them is to reduce the yeast colonization of the skin and control inflammation and scaling. While it's possible to control SD with a good treatment regimen, it's generally considered a chronic condition that waxes and wanes over time [124]. Currently, no permanent cure exists. For some people, one treatment alone may be enough to manage SD, while others may require a combination of treatments to maintain adequate control of the condition. This FAQS by no means covers all the possible treatment options. If you have a treatment or regimen that has worked for you and isn't listed, please forward the information to me and I'll include it in the list.

That being said, let's look at the treatments. (Note: to denote whether an item is used topically or orally, T indicates topically, O indicates orally, OTC (over the counter) indicates that the item can be purchased without a prescription in the U.S.).

Topical and Oral Corticosteroids

Topical and oral corticosteroids are used to reduce the inflammation associated with SD. For facial areas, low potency topical steroids creams, lotions, or ointments may be used. On the scalp and other areas, low to mid potency creams, ointments or lotions may be used as well.

Generally, physicians prefer to limit the use of topical steroids to relatively short periods of time, especially on delicate areas such as the face. This is done to avoid the possibility of side effects such as thinning skin, steroid rosacea, and perioral dermatitis. In some cases, the prolonged use of topical steroids can also lead to a rebound effect. Upon withdrawal of the steroid, the underlying condition can come back with a vengeance.

Oral corticosteroids are also occasionally used for SD. However, since they can have serious side effects, physicians usually reserve their use for cases that are severe or resistant to other treatments. Like topical steroids, oral corticosteroids can also lead to a rebound worsening of SD in some cases. Because of these potential side effects, topical and oral corticosteroids should be administered under the care of an experienced physician or pharmacist.

Some of the more common items prescribed for SD in this category are listed here by their generic names:

0.5% to 2.5% hydrocortisone (T, OTC)
alclometasone (T)
betamethasone valerate (T)
dexamethasone (T, O,)
fluocinolone acetonide (T)
fluticasone propionate (T)
hydrocortisone valerate (T)
mometasone (T)
prednisone (O)
tridesilon (T)
triamcinolone (T)

Topical and Oral Antifungals

Topical and oral anti-fungals are used to reduce the skin colonization by the malassezia yeast. In doing so, SD often improves since fewer yeast are available to trigger an inflammatory response. While the number of yeast on skin can be reduced, completely and permanently eradicating them is considered to be difficult, if not impossible [122]. As such, upon stopping anti-fungal treatment, the yeast often start to re-colonize the skin and SD symptoms may resurface. Physicians and pharmacists often try to address this by advising patients to continue using anti-fungal treatments for maintenance purposes even after symptoms clear.

An added benefit of some anti-fungal agents is that they may also have some anti-inflammatory properties [39]. And, unlike topical steroids, topical anti-fungals can be used for prolonged periods without causing skin thinning [39]. They can be applied in creams, lotions, foams, ointments, powders, gels, or shampoos for body, facial, and scalp use.

In some cases, oral anti-fungals may also be used. However, many of the oral anti-fungal agents can have serious side effects. As such, physicians may limit their use to SD that is either severe or resistant to other treatments.

Here's some of the more common anti-fungal agents available listed by their generic names:

benzoyl peroxide (T, OTC)
bifonazole (T)
chloroxine (T, OTC)
ciclopiroxolamine (T)
climbazole (T)
clotrimazole (T, OTC)
coal tar (T, OTC)
fluconazole (T, O)
flutrimazole (T)
itraconazol (T, O)
ketoconazole (T, O)
LCD (liquor carbonis detergens -- coal tar solution)(T, OTC)
lithium succinate (T)
miconazole (T, OTC)
nystatin (T)
piroctona olamina (T, OTC)
povidone iodine (T, OTC)
propylene glycol (T, OTC)
terbinafine (T - OTC, O)
sertaconazole (T)
selenium sulfide (T, OTC)
sulfacetamide (T)
sulfur (T, OTC)
tea tree oil (T, OTC)
triclosan (T, OTC)
undecylenic acid (T, OTC)
vinegar + boric acid (T, OTC)
zinc pyrithione (T, OTC)

De-scaling Agents (keratolytics)

De-scaling agents (keratolytics) are used to address the flaky aspect of SD. This serves both a cosmetic and a practical purpose. Removing scale helps to return skin affected by SD to a more normal appearance. At the same time, scale removal may give topical treatments a better chance of reaching the underlying skin areas. Some of these agents work by decreasing the bond between the dead skin cells and the skin's outermost layer. Other agents may actually reduce the rate at which skin cells turnover, which in turn reduces flakiness.

These are the most common agents in this class used for SD. Again, they are listed by their generic names:

calcipotriene (T)
carbamide (T, OTC)
coal tar (T, OTC)
salicylic acid (T, OTC)
urea (T, OTC)
zinc pyrithione (T, OTC)

Topical Immunomodulators

Topical immunomodulators are a relatively new class of treatment agents that are proving to be useful for controlling SD. As their name suggests, these medicines modulate the local immune factors that are involved in the SD inflammation process. Available in creams and ointments, their primary benefit is that they can reduce and control inflammation without the side effects of topical steroids. And, they're also safe to use on delicate skin areas like the face and can be used for prolonged periods. The commonly prescribed agents in this class include:

pimecrolimus (Elidel) (T)
tacrolimus (Protopic) (T)

Miscellaneous Treatments

Miscellaneous treatments include items that don't fall neatly into any of the above categories. Due to the variety in this category, each item will be discussed separately.

alpha lipoic acid (T, O, OTC)-- anecdotal claims suggest that alpha lipoic acid 5% applied topically reduces skin inflammation. Some claims have been made that it has provided some benefit in reducing inflammation in rosacea, and thus might also work for SD. [120]

aloe vera (T, OTC)-- there are anecdotal reports that it may be used to relieve the itching and inflammation associated with SD. Two studies have also concluded that it has anti-fungal activity [84],[99]. It's available in many forms including creams, gels, lotions, oils, and shampoos. It's probably best to look for products like pure aloe vera juice or gels that contain fewer ingredients that might bother sensitive skin.

anti-androgens (O)-- anti-androgens such as spironolactone, cyproterone acetate (androcur), and various oral birth control medicines may be useful for women when oily skin is believed to contribute to SD [64],[88] since they can reduce sebum output. These agents should not be used in men due to potential feminizing side effects such as loss of libido and gyneocomastia (breast growth). They should only be used under the care of a physician.

antihistamines (O, T, OTC)-- these are used primarily to reduce itching, if present. However, research studies suggest that some antihistamines have anti-inflammatory properties [104],[118], and thus, might be beneficial in inflammatory skin disorders such as SD. They're also used to good effect in other inflammatory and allergic skin disorders such as atopic dermatitis and urticaria (hives). There are many different antihistamines available both over the counter and via a physician's prescription. Newer antihistamines such as Claritin (loratadine), Zrytec (cetirizine), and Allegra (fexofenadine) are supposed to cause less drowsiness than older antihistamines such as Benadryl (diphenhydramine), Chlor-trimeton (chlorpheniramine), etc.

aspirin (O, T, OTC)-- oral low dose aspirin (80mg daily) is sometimes used to reduce inflammation associated with rosacea [36],[81]. As such, it might also be useful for reducing the inflammation that accompanies SD. Discuss this with your doctor if you have any other medical conditions that might be aggravated by aspirin, such as asthma, hives, ulcer, etc.

b-complex vitamins (O, OTC)-- some sources indicate a deficiency of B vitamins might be associated with SD [16],[33],[46],[119]. In cases of SD associated with true B vitamin deficiency, replenishing the body's depleted stores via supplements or vitamin rich foods should clear the condition rather quickly [33].

blue light (T, OTC)-- some research and suggests that blue light (420nm) therapy seems to improve SD by killing off the malassezia yeast on the skin [97],[113]. These treatments can be administered at home or at a health-care facility. Several vendors of blue light systems and bulbs can be found via the internet. It appears that blue light night also be used in conjunction with red light (660nm) which reportedly has anti-inflammatory properties.

borage oil (T, O, OTC)-- one study reports that topical and oral use of this oil rich in GLA (gamma lineolic acid) may improve skin conditions like eczema and SD [127]. It's believed that these fatty acids down-regulate the production of inflammatory substances within the body.

boswellia extract (O, OTC)-- this herbal extract has been shown to have anti-inflammatory properties when taken orally [91],[93]. As such, some individuals affected by SD have proposed that it might be useful for reducing the inflammatory aspect of SD.

cod liver oil (O, T, OTC)-- oral use of this oil rich in DHA (docosahexaenoic acid), EPA (eicosapentaenoic acid), and vitamins A & D, may have anti-inflammatory effects within the body. Consequently, it might prove useful in skin conditions like SD at a dose of one to two tablespoons daily. Economical generic versions are usually available in pharmacies or via the internet. Orange or other flavored versions are also available to cover the fishy taste.

crude honey (T, OTC)--some researchers have suggested that crude honey (not filtered or processed) in a ratio of 9 parts honey to one part warm water has a beneficial effect on SD [3],[40]. The honey was applied for three hours (then rinsed off) daily for one month. Supposedly, this resulted in a marked improvement. PS -- if you try this, steer clear of bees and hungry bears :)

cyclosporine (O)-- this immunomodulating drug is occasionally used orally for severe or generalized cases of SD [132]. However, it can have serious side effects and requires close supervision by an experienced physician.

evening primrose oil (T, O, OTC)-- some studies and anecdotal reports suggest that topical and oral use of this oil rich in GLA (gamma lineolic acid) may improve skin conditions like eczema and SD [116]. It's believed that these fatty acids down-regulate the production of inflammatory substances within the body.

flax seed oil (T, O, OTC)-- some studies and anecdotal reports suggest that oral use of this oil rich in omega-3 fatty acids may improve skin conditions like eczema and SD [101],[106]. It's believed that these fatty acids down-regulate the production of inflammatory substances within the body.

fish oil (T, O, OTC)-- some studies report that oral use of this oil rich in DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid) may have anti-inflammatory effects within the body. Some anecdotal reports have mentioned that it might prove useful in skin conditions like SD.

glycerin (T, OTC)-- a recent study suggests that glycerin may be beneficial for skin conditions such as SD [92]. It was reported that topical application may help normalize the rate at which skin cells turnover. Besides that, glycerin has long been used as a skin humectant. Some anecdotal reports state that one part glycerin to two parts water seems to control flaking and dryness without resorting to oil based moisturizers. Gylcerin can be found on the shelves in many pharmacies.

green tea (T, O, OTC) -- Green tea is reported to have anti-oxidant and anti-androgenic properties [111]. As such, anecdotal reports have implied that green tea may have some benefit for SD when used either topically, orally, or both.

isotretinoin (accutane) (O)-- this powerful drug, with anti-inflammatory and anti-seborrheic properties, is primarily used to treat cystic or severe acne. However, on occasion it's used for severe or stubborn cases of SD, or when SD is accompanied by rosacea [131]. When used for SD, a low dose regimen (2.5 mg to 5 mg per day) might be the way to go since one study has found that this dosage scheme greatly reduces side effects, yet sebum output is still reduced by up to 65% [35]. Interestingly, one physician reported two cases of SD that were actually worsened by accutane [131]. However, no information was provided regarding the dosages used in those cases. Please note: any use of accutane requires close supervision by an experienced physician, especially for women of child bearing age since it can cause severe birth defects.

low carb diet -- some anecdotal reports claim that maintaining a low carb diet may improve SD by stabilizing blood sugar levels, hormones, and enzymes, etc. The end result is claimed to be better overall health , better immune function, down-regulation of inflammatory processes, etc.. There is much debate over these theories and experts offer no clear cut answers one way or the other.

low yeast diet -- some sources suggest that adhering to a low yeast diet may be helpful for SD. It's proposed that folks with SD may also be sensitive to yeasts such as baker's and brewer's yeast, which are commonly found in many foods. Low yeast diets commonly recommend avoiding baked foods that use yeast, over-ripe fruit, fermented foods, alcoholic beverages, fungi (mushrooms), B vitamins prepared from yeast sources, etc. By avoiding these foods, it's proposed that the overall allergen load on the body is reduced for individuals sensitive to yeasts. This in turn, so the theory goes, may lead to an improvement in SD. There's plenty of information about low yeast diets on the web. Try a Google search for "low yeast diet" or "foods that contain yeast". Here's one such diet suggestion Dr. Andrew Lockie -- Yeast and mould free diet.

metronidazole (T)-- this antibiotic is used topically primarily for its reported ability to reduce skin inflammations. It's widely prescribed for rosacea and sometimes SD as well.

narrow-band ultraviolet B light(T)-- some researchers have found that this treatment improves SD [34]. This form of ultraviolet light therapy is usually administered in a health care professional's office or hospital for several short sessions. This treatment may be reserved for more severe or stubborn cases.

olive leaf extract (O, T, OTC)-- One study reports that this herbal extract has anti-fungal and anti-bacterial properties [114]. Perhaps, that might explain the anecdotal reports of some SD sufferers who have claimed that using this natural extract topically or orally may improve SD.

probiotics (O, T, OTC)-- probiotics are live microorganisms that are believed to provide health benefits when they are part of the gastrointestinal flora environment. One study suggested that some individuals with SD seem to have unbalanced gastrointestinal tract flora [115]. Consequently, some anecdotal reports suggest that consumption of probiotics may improve SD by re-balancing the intestinal flora to include more beneficial organisms, which in turn might help to balance the immune system.

PUVA (psoralen plus ultraviolet A) (T, O)-- this treatment involves taking oral psoralen, a drug that increases the skin's photo-sensitivity, and then exposing the skin to ultraviolet A light therapy. This treatment is often used in psoriasis, but it is also used in SD on occasion [73].

sun exposure -- some individuals find that their SD improves with light to moderate sun exposure. Yet, others claim that the sun only worsens their SD. And, it's very interesting to note that one group of scientists studied Swiss mountain guides and found that they had higher rates of SD than the general population. They concluded that the SD in these guides might have been related to a weakening of their skin's immune system brought on by UV damage from the sun [62]. Considering that, avoiding excessive sun exposure seems like a good idea.

turmeric (O, OTC)-- this spice is widely used in many parts of the world such as India. It contains curcumin which has been found to have anti-inflammatory and antioxidant properties [109],[126]. As a result, it may help reduce inflammation in SD. It's usually very economical and available in supermarkets or in Indian/Asian grocery stores. A few teaspoons daily added to water should suffice. Some may find it has a rather strong taste. Mixing it with fruit juices or other flavoring agents may make it more pleasing to the palate.

vinegar (T, O, OTC)-- some anecdotal reports suggest that vinegar applied topically, and in some cases, orally consumed, can improve SD. It is believed to act as an anti-fungal agent via its acidic ph properties. Supposedly, the malassezia yeast don't thrive very well in acidic environments. Applying vinegar topically is supposed to create a more acidic skin environment which hinders the yeast's ability to colonize the skin. It is also combined with 2% boric acid for similar purposes.

vitamin E (O, OTC)-- one team studied the vitamin E status in individuals with SD and concluded that they had lower levels of the vitamin in comparison with people without SD [69]. As such, it might be wise to ensure that you eat enough vitamin E rich foods or take a supplement

zinc (dietary) (O, OTC)-- two groups of researchers have suggested that low levels of zinc in the body might be associated with SD [2],[30]. With that in mind, it might be beneficial to analyze your diet to ensure that your body is getting enough zinc.

zinc oxide (T, OTC)-- this item has long been used in cream or ointment bases for skin inflammations. One of its most common applications is for diaper rash where it probably has a beneficial effect by providing a protective film on the skin. With SD, it may provide relief from flaking, itching and irritation in a similar manner.

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Seborrheic Dermatitis and Skin Care

Generally, the overall goal of skincare for SD is to gently clean the skin while attempting to avoid further damage and irritation. As a first step in that direction, one should try to determine their skin type. Skin is commonly categorized as dry, combination, or oily. Skin care routines for each category differ in some respects.

For most skin, a mild soap or soap-less cleanser would probably be a good start. For very sensitive skin, choosing fragrance free and hypo-allergenic cleansers may offer the least irritating solution. However, when the skin is very dry or during a more severe flare of SD, it may be best to avoid cleansers and wash with only water or two parts water mixed with one part glycerin. In all cases, cool to lukewarm water should be used--not hot, as that has a tendency to further aggravate and dry out already inflamed skin.

Dry skin should probably be washed once a day at most. After washing, skin should be allowed to air dry or gently patted dry with a clean towel. Some individuals with dry skin may find they need or want to use a moisturizer following bathing. If you are using a medicated cream or ointment such as Nizoral, Elidel, etc., you may find that these items can replace the need for a moisturizer.

If you do decide to use a moisturizer, choose with it care for two reasons. First, given the sensitive nature of skin affected with SD, anything applied to the skin has the potential to create further irritation. Second, products that contain oils should probably be avoided since the malassezia yeast associated with SD tend to thrive in oily skin environments. So, you'll probably need to carefully look at the ingredients in moisturizers for possible irritants and oily additives.

Combination skin is a bit different in that frequent washing may keep the oily areas of the skin relatively clean, but the dry areas of the skin will dry out even further. To avoid this, you might find it helpful to only apply a cleanser to the oilier areas of the skin and cleanse dry areas with only water. Then rinse all areas with water and dry. If needed, a moisturizer may be applied to the dry areas while avoiding the oiler skin zones such as the nose and forehead.

Oily skin may need to be cleansed twice a day. However, the advice with regard to mild cleansers and cool to lukewarm water should still be followed. Often, there is a common misconception that oily skin needs to be cleansed with strong cleansers and hot water to remove excess oils. Yet, such a routine will likely lead to a weakened skin mantle and increased susceptibility to irritation. With oily skin, one should also avoid applying moisturizers or oily topical products.

For males, SD can complicate shaving routines. Some men have found that shaving with an electric razor is less irritating than shaving with a razor blade. A helpful hint for using electric razors is to apply corn starch to dry skin before shaving. This tends to give a smoother, less irritating shave. If you prefer a wet shave with a razor, choose your shaving products carefully since skin affected by SD can be very sensitive to grooming products. Check labels for potentially irritating ingredients like dyes, perfumes, alcohol, menthol, euclyptus, etc. In the USA, Edge Fragrance Free or Aveeno Sensitive Skin shave gels are free of dyes and perfumes and may be a good choice for skin affected by SD. In general, shaving gels or oils seem to reduce irritation better than shaving cream. If possible, use razors for no more than three or four shaves on heavier beards, and, perhaps, four to seven times for lighter beard growth. Try not to press down heavily on the razor while shaving and avoid shaving against the grain of hair growth. Always rinse skin well with cool water after shaving and don't apply aftershave lotions or tonics which often contain alcohol and perfumes that can further irritate SD. Pat skin dry with a clean towel or let it air dry.

Since SD often affects the scalp, special routines may need to be followed to keep the affected areas as healthy as possible. One of the most common methods of treating SD on the scalp is via medicated shampoos. Depending upon the situation, a physician or pharmacist may recommend a particular medicated shampoo and guidelines for usage. At times, this may include allowing the shampoo to soak on the scalp for a short period before rinsing. Initially, you may be instructed to use the medicated shampoo every day or every other day until your condition stabilizes. Then, a less frequent application schedule may be recommend for maintenance.

In addition to shampoos you may be required to use medicated lotions that are applied for a period (sometimes overnight) before or after washing. Your physician may also suggest that you wear a disposable shower cap before retiring to bed to increase the effectiveness of topical agents, and to help keep bed linens and clothing clean. As a result of these treatment regimens, you might find it necessary to adjust your hair care routines. Drying your hair with a hair dryer and hot air, for example, may increase scalp dryness and further irritate the areas affected by SD. Or, other styling products or chemicals might be irritating as well. If you suspect that your hair care products or usual routine might interfere with your treatment program or vice versa, consult your physician and pharmacist to be sure that your concerns are addressed.

Important note: When considering soaps, cleansers, or topical treatments in general, remember that any agent applied to the skin can lead to adverse events such as irritation, itching, dryness, redness, etc. In such cases, it may be difficult to determine whether the side effect is due to the active ingredients or the topical vehicle used to deliver the active ingredients. If you're concerned about a possible negative reaction to a topical treatment, it might be wise to test the treatment for a few days on a small spot of your inner arm. If no reaction is noted within a few days, it's probably safe to apply to other areas as directed by a physician or pharmacist. However, in some instances, adverse events might only surface after using an item topically for awhile. In any case, if you ever note that your condition is worsening rather than improving, contact your physician or pharmacist to discuss your options.

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Interesting Links

Sebderm group
A good Yahoo discussion and support group for SD. Contains useful archives that group members can search.

Rosacea Blog
Seb Derm and Rosacea are often companions. The Rosacea Blog is an excellent resource for timely information regarding rosacea primarily, with occasional seb derm related items as well.

The Merck Manual
A time honored medical reference that provides solid information on a wide variety of illnesses and treatments.

ScienceDaily Magazine
The latest health-care breakthroughs are often reported here.

Skin and Connective Tissue Diseases
An interesting resource for skin diseases.

PDR Herbs
The indispensable Physician's Desk Reference to Herbs and Nutrition. It provides detailed information about nutritional issues supported by solid references.

Martindale's Health Science Guide
An excellent and very comprehensive source for medical information.

The very valuable Pubmed system. Here, you can search hundreds of thousands of medical abstracts for free !

Dr. Gabe Mirkin
Dr. Mirkin provides a wide range of medical information. His valuable archives can be searched for gems. All free !

Atlas of dermatology
A fairly good source of information about skin diseases. Some photos as well.

This dermatology trade journal is a good place to find easy to understand dermatology related news.

Internet Dermatology Society
Another good source of information about skin diseases. Many photos too.

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