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Topical treatments for seborrhoeic dermatitis of the scalp – need for more evidence

3 Sep, 15 | by BMJ Clinical Evidence

Diphoorn, JanoukBy Janouk Diphoorn and Luigi Naldi

Seborrhoeic dermatitis is one of the most common skin conditions. It occurs in 3 to 10% of the population. The scalp is one of the areas most frequently involved. For people with seborrhoeic dermatitis of the scalp it can be very distressing since there is itching and visible scaling, which can cause social embarrassment.

As the condition tends to relapse after treatment, it is important to consider maintenance treatment after clearance. Nowadays the most used treatment in clinical practice is ketoconazole, which is thought to inhibit the Malessezia furfur yeasts considered to play a role in the development of this condition. For the acute phase corticosteroids are often added to inhibit the inflammatory reaction.

In general there is limited evidence available on the treatment of seborrhoeic dermatitis of the scalp with topical agents. This is unfortunate as it is such a common condition. Only ketoconazole and ciclopirox were studied in multiple RCT’s that met the inclusion criteria for our recent BMJ Clinical Evidence systematic overview. For other topical treatments such as bifonazole, selenium sulfide, tar shampoo and corticosteroids the evidence was much sparser.

For each type of topical treatment included in this overview, we looked at RCTs and systematic reviews of RCTs comparing the active treatment with a placebo intervention. In this way it possible to establish the difference between the natural course of the disease and the course of the disease with a treatment, which is important to determine if a treatment has any beneficial effect at all. From the results of the studies it became clear that treatment can definitely improve seborrhoeic dermatitis of the scalp and should be considered in every patient that is disturbed by the symptoms of his condition. This way the physical complaints, and also the social consequences, can be decreased.

One of the more established treatments for seborrhoeic dermatitis of the scalp is ketoconazole. The studies confirmed that it appears to be beneficial for both clearance of the initial flare and maintenance of the improved clinical condition. In this update of the review, ciclopirox was the only other treatment that also seemed to be beneficial. In one three arm study ketoconazole and ciclopirox were compared directly, showing a similar effectiveness regarding clearance. However, in the longer term ketoconazole appeared to be more effective. We plan to look at head to head comparisons in more detail at the next update. Ketoconazole and ciclopirox both seem to have no relevant adverse effects, in contrast to corticosteroids which in the long term may cause skin atrophy and folliculitis.

From our systematic overview of the high quality published evidence it became clear that there was a need for more research on the treatment of seborrhoeic dermatitis of the scalp. Another issue is that the trials should focus specifically seborrhoeic dermatitis, not on dandruff as was the case in some of the current studies for ketoconazole, since any scalp condition that produces scales could be labeled as dandruff. Dandruff stands for the dry, flaking desquamation, which is a symptom of seborrhoeic dermatitis, but it might also be present in other diseases.

Most patients with seborrhoeic dermatitis can be treated very well in the primary care setting. However, when doubts about the diagnosis arise, for example when there are other clinical features which might indicate another disease (e.g. psoriasis, rosacea or systemic lupus erythematosus) or if there is no sufficient response to treatment, patients should be referred to the dermatologist for evaluation and treatment.

Janouk Diphoorn and Luigi Naldi are authors of the Clinical Evidence topic on Seborrhoeic dermatitis of the scalp.

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