Seborrheic dermatitis: Diagnosis and treatment

Seborrheic dermatitis is one of many skin conditions that causes an itchy rash

A board-certified dermatologist can tell you which skin condition you have and create a treatment plan tailored to your needs.

How do dermatologists diagnose seborrheic dermatitis?

To diagnose this condition, your dermatologist will:

• Ask about your symptoms.

• Review your medical history with you, asking if you have allergies or other medical conditions.

• Look closely at the skin with signs of seborrheic dermatitis.

That’s often all that’s needed to diagnose seborrheic dermatitis or cradle cap (a type of seborrheic dermatitis that babies develop, usually on their scalp).

However, some people have seborrheic dermatitis and another skin condition. For example, it’s possible to have both seborrheic dermatitis and psoriasis, which is often called sebopsoriasis.

Having two skin conditions can make it difficult to clearly see each condition. If your dermatologist sees signs of two skin conditions, they may remove a small amount of skin. This procedure is called a skin biopsy. It can be performed during your office visit while you remain awake.

The small amount of skin will be examined under a microscope by a dermatopathologist (a doctor who specializes in both dermatology and pathology), who will look for signs of a variety of skin conditions.

After your dermatologist has all the information, they will talk with you about what’s going on. If you have seborrheic dermatitis, your dermatologist will discuss treatment with you.

How do dermatologists treat seborrheic dermatitis?

The goals of treatment are to:

• Clear or lessen the rash, including scales

• Ease the itch and swelling

• Prevent flare-ups

The first step is to get seborrheic dermatitis under control. Once that happens, your dermatologist may change your treatment to help you maintain results.

A treatment plan may include one or more of the following.

Skin care

The right skin care can help calm your irritated skin and keep seborrheic dermatitis under control. Your dermatologist may recommend one or more personal care products, including a cleanser, shampoo, or moisturizer. Washing with zinc soap is often recommended.

Dandruff shampoo

A dandruff shampoo can treat mild to moderate seborrheic dermatitis on your scalp. For some people, that may be all the treatment they need.

These shampoos contain different ingredients that treat the itch, rash, flaking/scales, and irritation.

To get seborrheic dermatitis under control, you’ll use this type of shampoo as often as directed. If you have straight or wavy hair, you may use dandruff shampoo 2 to 3 times a week. However, if you have curly or tightly coiled hair, your dermatologist may recommend using the shampoo once a week.

Dandruff shampoo can also help treat other areas of your body with seborrheic dermatitis, so your dermatologist may also recommend shampooing your beard, face, or another area.

To prevent flare-ups, patients often continue to use dandruff shampoo once a week.

You’ll find many dandruff shampoos. It’s important to use the one or two that your dermatologist puts in your treatment plan. Different shampoos work differently. For example, some dandruff shampoos control the overgrowth of yeast that people with seborrheic dermatitis have. Other shampoos help reduce scale.

Some people find that a shampoo no longer works as well as it once did. If this happens, let your dermatologist know. It may be helpful to rotate dandruff shampoos.

Should you need a stronger dandruff shampoo, your dermatologist may prescribe:

Ciclopirox: This prescription shampoo works to clear the rash, scales, and itch.

The U.S. Food and Drug Administration (FDA) has approved it to treat patients 16 years of age or older who have seborrheic dermatitis on their scalp. Most patients use this shampoo twice a week for 4 weeks, waiting at least 3 days between shampoos. If you have coily hair, your dermatologist may recommend using this shampoo less often.

In two clinical trials, 58% and 26% of patients had little or no seborrheic dermatitis after using this shampoo for 4 weeks. During these trials, a few patients developed side effects. Increased itch was reported by 1%, and 1% developed irritation where they had applied the shampoo.

If you develop an irritated scalp while using this shampoo, stop using it and tell your dermatologist. Also, let your dermatologist know if you don’t see any improvement in 4 weeks.

• Brand name: Loprox

Medicated creams, foams, gels, ointments, and solutions

When seborrheic dermatitis develops on the skin, dermatologists often treat it with medication that you apply to the rash and other signs. These medications include:

Antifungal cream, gel, or foam: This type of medication is often included in a treatment plan.

Ketoconazole is a medication that’s often prescribed. It can diminish the rash, itch, and scale. The FDA has approved topical (applied to the skin) ketoconazole to treat seborrheic dermatitis in people 12 years of age and older who have a healthy immune system.

Different types of this medication are applied differently. For example, you apply the foam twice a day and the gel twice a week. Be sure to read the directions carefully.

Possible side effects include burning, stinging, or irritation on skin treated with ketoconazole.

• Brand names: Extina, Ketodan, and Xolegel

Corticosteroid medication you apply to your skin or scalp: If an antifungal or dandruff shampoo fails to clear your skin or scalp, your dermatologist may add a corticosteroid to your treatment plan.

This medication can quickly reduce inflammation, which reduces discoloration and itch. It’s also prescribed to get a flare-up under control quickly.

Patients usually apply a corticosteroid like hydrocortisone cream once or twice a day. Be sure to follow your dermatologist’s instructions carefully, as this helps to avoid possible side effects.

Roflumilast foam: This medication works on the rash and its accompanying discoloration (red, pink, or a shade darker than your skin tone), scaling, (large, greasy, scales that flake off), and itch. It can also treat hyperpigmentation (dark spots) and hypopigmentation (light spots) that can develop on the skin, usually in people with darker skin tones.

The FDA has approved this medication to treat seborrheic dermatitis in people 9 years of age and older. It can be applied to any skin with seborrheic dermatitis, including the nose, eyebrows, ears, eyelids, and scalp.

Most patients apply this medication once a day for as long as needed.

In a clinical trial, 68.3% of the patients using roflumilast had clear or almost clear skin within 8 weeks. Within 8 weeks, 64.7% of the patients who had dark spots saw their hyperpigmentation disappear, and 46.2% who had light spots saw these go away. A few patients using roflumilast developed new dark or light spots.

In these clinical trials, 3% of patients developed side effects. Most of these were mild and included stinging, burning, or pain where they applied roflumilast.

• Brand name: Zoryve

Topical calcineurin inhibitor (TCI): Two medications, pimecrolimus cream and tacrolimus ointment, are TCIs. These medications work on inflammation, which can reduce the discoloration and swelling.

In studies, patients with seborrheic dermatitis who were treated with these medications saw less seborrheic dermatitis within 2 weeks. Researchers also found that if signs and symptoms returned, they were milder than before.

These medications can be prescribed short-term to treat people who have a healthy immune system.

Side effects include a warm or burning sensation where the medication is applied.

• Brand names: Elidel (pimecrolimus cream), Protopic (tacrolimus ointment)

Propylene glycol: This medication can reduce scale, moisturize the skin so that it’s not so dry, and reduce yeast on the skin called P. orbiculare.

In studies, dermatologists have found that a solution which includes propylene glycol can reduce symptoms. Patients usually apply this solution once a day for 3 weeks.

Side effects may include stinging or burning when you apply the medication.

Medication that works throughout the body

Skin care along with medicated shampoos and topical (applied to the skin) medications can often control seborrheic dermatitis. If this treatment fails to work or you have widespread seborrheic dermatitis, your treatment plan may include:

Oral (take by mouth) antifungal: Your dermatologist may prescribe an antifungal medication, such as itraconazole or terbinafine. These medications can reduce symptoms. When using this medication, the goal is to reduce symptoms and then switch to a topical medication to maintain your results.

It’s important to take this medication exactly as directed.

Light therapy: A type of treatment called UVB light therapy may help clear a widespread rash and scales on the skin and scalp.

If this is an option, you’d go to a treatment center at a hospital or medical office that offers UVB light therapy. For treatment to be effective, most patients need 3 treatment sessions a week for up to 8 weeks.

Self-care can help you get the best results from treatment

To get the best results from treatment, dermatologists recommend taking proper care of your skin and other self-care techniques. To see the self-care that dermatologists advise, go to: Seborrheic dermatitis: Self-care.

References
Baiter K. “FDA approves historic roflumilast foam 0.3% for seborrheic dermatitis.” Dermatology Times. Dec 15, 2023. Last accessed: March 25, 2024.

Blauvelt A, Draelos ZD, et al. “Roflumilast foam 0.3% for adolescent and adult patients with seborrheic dermatitis: A randomized, double-blinded, vehicle-controlled, phase 3 trial.” J Am Acad Dermatol. 2024 Jan 20:S0190-9622(24)00107-5. doi: 10.1016/j.jaad.2023.12.065. Epub ahead of print.

Borda LJ, Perper M, et al. “Treatment of seborrheic dermatitis: A comprehensive review.” J Dermatolog Treat. 2019 Mar;30(2):158-69.

Cook BA, Warshaw EM. “Role of topical calcineurin inhibitors in the treatment of seborrheic dermatitis: A review of pathophysiology, safety, and efficacy.” Am J Clin Dermatol. 2009;10(2):103-18.

Dall'Oglio F, Nasca, et al. “An overview of the diagnosis and management of seborrheic dermatitis.” Clin Cosmet Investig Dermatol. 2022 Aug 6;15:1537-48.

Elewski, B. “Safe and effective treatment of seborrheic dermatitis.” Cutis. 2009;83:333-8.

Emtestam L, Svensson Å, et al. “Treatment of seborrhoeic dermatitis of the scalp with a topical solution of urea, lactic acid, and propylene glycol (K301): Results of two double-blind, randomised, placebo-controlled studies.” Mycoses. 2012 Sep;55(5):393-403.

Gupta AK, Nicol K, et al. “Role of antifungal agents in the treatment of seborrheic dermatitis.” Am J Clin Dermatol. 2004;5(6):417-22.

Loprox (ciclopirox) Shampoo 1% - Package insert

Okokon EO, Verbeek JH, et al. “Topical antifungals for seborrhoeic dermatitis.” Cochrane Database Syst Rev. 2015 May 2;2015(5):CD008138.

Written by:
Paula Ludmann, MS

Reviewed by:
Elaine T. Kaye, MD, FAAD
William Warren Kwan, MD, FAAD
Ata Moshiri, MD, FAAD

Last updated: 5/14/24