Hospital Medicine

Seborrheic dermatitis

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Seborrheic dermatitis

I. What every physician needs to know.

A common chronic disorder, characterized by greasy scales overlying erythematous patches or plaques usually on the scalp, central face, and anterior chest (locations with increased sebaceous gland activity). Little is known about the etiology, but several factors are associated with developing seborrheic dermatitis including hormone levels, fungal infections (yeast in the genus Malessezia), nutritional deficits, and neurogenic factors.

II. Diagnostic Confirmation: Are you sure your patient has seborrheic dermatitis?

There are no diagnostic criteria.

A. History Part I: Pattern Recognition:

Usually presents as scalp scaling (dandruff) or as mild or moderate erythema involving the nasolabial folds, frequently during times of stress or lack of sleep.

B. History Part 2: Prevalence:

  • Without rigorous diagnostic criteria, it is difficult to obtain accurate prevalence rates.

  • Affects approximately 5-10% of the general population. The typical patient is 30 to 60 years old.

  • Parkinson's disease, HIV infection, stroke, epilepsy, central nervous system (CNS) trauma, and facial nerve palsies seem to be associated with developing seborrheic dermatitis.

C. History Part 3: Competing diagnoses that can mimic seborrheic dermatitis.

  • Atopic dermatitis

  • Candidiasis

  • Dermatophytosis

  • Langerhans cell histiocytosis

  • Psoriasis

  • Rosacea

  • Systemic Lupus erythematosus

  • Tinea infection

Seborrheic dermatitis can usually be distinguished by its characteristic location and lack of systemic signs and symptoms. Biopsy is rarely indicated.

D. Physical Examination Findings.

Greasy scales overlying erythematous patches or plaques usually on the scalp, central face, post auricular skin, and anterior chest (locations with increased sebaceous gland activity).

E. What diagnostic tests should be performed?

Skin biopsy may be required to distinguish from other diseases on the differential diagnosis.

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

None

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

None

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

None

III. Default Management.

N/A

A. Immediate management.

Effective therapies for seborrheic dermatitis include anti-inflammatory (immunomodulatory) agents, keratolytic agents, antifungals, and alternative medications. There is no urgency to treat.

Facial dermatitis options:

  • Desonide topical 0.05% to affected area BID plus ketoconazole shampoo three times per week until disease resolves

OR

  • Tacrolimus ointment 0.03% or 0.1% to affected area BID until one week post resolution of rash

OR

  • Pimecrolimus cream 1% to affected area BID, discontinue when disease resolves

B. Physical Examination Tips to Guide Management.

Monitor involved areas for development of secondary bacterial infection.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

None

D. Long-term management.

May relapse frequently throughout life. Avoid stressors that trigger inflammation. For moderate to severe cases or with relapse, consideration can be given to prescribing itraconazole 200 mg PO qday x 1 week followed by 200 mg PO qday x the first 2 days of each month x 3 months.

IV. Management with Co-Morbidities

N/A

A. Renal Insufficiency.

No change in standard management.

B. Liver Insufficiency.

No change in standard management.

C. Systolic and Diastolic Heart Failure

No change in standard management.

D. Coronary Artery Disease or Peripheral Vascular Disease

No change in standard management.

E. Diabetes or other Endocrine issues

No change in standard management.

F. Malignancy

No change in standard management.

G. Immunosuppression (HIV, chronic steroids, etc).

No change in standard management.

H. Primary Lung Disease (COPD, Asthma, ILD)

No change in standard management.

I. Gastrointestinal or Nutrition Issues

No change in standard management.

J. Hematologic or Coagulation Issues

No change in standard management.

K. Dementia or Psychiatric Illness/Treatment

No change in standard management.

V. Transitions of Care

A. Sign-out considerations While Hospitalized.

None

B. Anticipated Length of Stay.

Not a disease managed as an inpatient.

C. When is the Patient Ready for Discharge?

Not applicable.

D. Arranging for Clinic Follow-up

Follow up response to treatment in 2-4 weeks.

1. When should clinic follow up be arranged and with whom?

Internist or dermatologist.

2. What tests should be conducted prior to discharge to enable best clinic first visit?

Consider HIV testing.

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit?

None.

E. Placement Considerations.

None. Let a skilled nursing facility (SNF) or rehab facility know that this is not a contagious condition.

F. Prognosis and Patient Counseling.

No long-term sequelae. Response to treatment is good.

VI. Patient Safety and Quality Measures

A. Core Indicator Standards and Documentation.

None.

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

None.

What's the evidence?

Schwartz, RA. "Seborrheic Dermatitis: An Overview". Am Fam Physician. vol. 74. 2006. pp. 125-30.

Nnoruka, EN. "Correlation of mucocutaneous manifestations of HIV/AIDS infection with CD4 counts and disesae progression". International Journal of Dermatology. vol. 46. 2007. pp. 14-18.

Ghodsi, SZ. "Efficacy of Oral Itraconazole in the Treatment and Relapse Prevention of Moderate to Severe Seborrheic Dermatitis: A Randomized, Placebo-Controlled Trial". Am J Clin Dermatol. vol. 16. 2015. pp. 431-437.

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