Scalp Seborrheic Dermatitis

In adults, one of the earliest signs of the condition on the scalp may be dandruff, followed by redness and increased scaling. Over time, well-defined plaques often form, which may coalesce to cover a larger area, extending to the forehead. Serous crusts are sometimes observed, and after their removal, a weeping surface is revealed. Other clinical forms of seborrheic dermatitis on the scalp may include round, polycyclic or irregularly shaped patches, as well as psoriasiform and exudative lesions. In severe cases, the entire surface of the scalp may be covered with greasy, serous crusts that emit an unpleasant odor.

Seborrheic Dermatitis of the Face

On the face, eruptions are localized on the cheeks, nasal wings, forehead, nasolabial folds, inner part of the eyebrows and typically occur in association with scalp involvement. Eruptions are characterized by erythematous patches of round or circular shape, infiltration, scaling and crusting. The skin in the affected area may be grayish-white or yellowish-red in color and the follicular openings are sharply defined. Pruritus is often observed. Facial involvement usually coexists with seborrheic dermatitis of the scalp. Unilateral localization of seborrheic dermatitis patches on the face may occur in cases of unilateral innervation disorders or after a stroke.

Perinasal Seborrheic Dermatitis

Perinasal seborrheic dermatitis is a variant of seborrheic dermatitis of the face and is most commonly seen in young women and less commonly in men. Yellowish or reddish-yellowish scaly patches appear in the nasolabial folds and on the sides of the nose. This may be the only manifestation of the condition.

Seborrheic Blepharitis

Eye involvement in seborrheic dermatitis is characterized by blepharitis, which presents as mild erythema and the accumulation of honey-yellow crusts along the eyelid margins and on the corneal scales around the eyes. The conjunctiva of the eyes may sometimes appear injected. When the glabella is affected, the folds in the corners of the eyes may be covered with light scales.

Ear Seborrheic Dermatitis

In this area, seborrheic dermatitis has similarities to external otitis. Clinically, it manifests as erythema, scaling and pruritus of the external auditory canal. It may be an isolated condition or coexist with manifestations of the disease on other parts of the body.

Chest Seborrheic dermatitis

On the trunk and extremities, eruptions appear as oval, round, or irregularly shaped yellowish-pink patches or plaques with scaling and well-demarcated borders. Fine nodules may be present in the center. The predominant localization is the upper part of the trunk, especially the chest and shoulders, less commonly the upper extremities. Secondary infection is possible, resulting in the spread of secondary pyoderma beyond the initial areas of skin involvement.

Intertriginous Seborrheic Dermatitis

Intertriginous areas such as behind the ears, neck, axillary and groin folds, under the breasts and around the belly button are affected.

Erythema, swelling, and painful cracks often appear behind the ears and on the skin under the earlobes. In the axillary folds, eruptions occur in the center and gradually spread to the surrounding skin. Both folds are affected. Clinically, they appear as scaly erythema or as merging crusts and cracks. Seborrheic dermatitis in the axillary folds bears a strong resemblance to allergic dermatitis from deodorants but differs from dermatitis caused by clothing items (the latter is localized at the periphery of the fold and spares the center). Seborrheic dermatitis of the inguinal and perianal folds closely resembles dermatomycosis or candidiasis and sometimes presents with inverse psoriasis. The combination of psoriasis and seborrheic dermatitis (sebopsoriasis) in these folds is not uncommon. Erythema, swelling, oozing, painful cracking, and scaly crusts often develop in skin folds.

Anogenital Seborrheic Dermatitis

Rarely, the anogenital area may be involved: penis, vulva, perianal area, scrotum, and pubic area. A distinguishing feature is minimal scaling of the elements and the presence of papular elements. It can be difficult to differentiate from genital psoriasis.

Generalized Seborrheic Dermatitis

It is characterized by a widespread process affecting multiple areas of the body. In adult patients, generalized seborrheic dermatitis is often associated with lymphadenopathies and may resemble a fungal infection (tinea).

Seborrheic dermatitis may be associated with or exacerbated by certain systemic diseases. Parkinson's disease is often associated with severe refractory seborrheic dermatitis of the face and scalp. Severe skin changes resembling seborrheic dermatitis may complicate diabetes mellitus, especially in obesity, celiac disease, malnutrition, epilepsy, and drug-induced skin conditions (especially when treated with neuroleptics such as haloperidol, gold preparations, or arsenic).

Cradle Cap (Crŭsta Lacʹtea)

Occurs in over 50% of newborns and infants (up to 1-1.5 years of age) and is characterized by the presence of multilayered, greasy, sticky scales or crusts on the scalp, especially in the temporal area, with minimal redness of the skin. In some cases, when hygiene is poor, the scales may accumulate on hyperemic and swollen skin, often due to the involvement of conditionally pathogenic flora. The scales may accumulate, thicken and cover almost the entire scalp.

Seborrheic dermatitis in infants

Develops at about 1 month of age, often at the end of the first week to the beginning of the second week. It runs its course for 3-4 months and then resolves. There are three degrees of severity: mild, moderate and severe. The disease begins with erythema and slight skin infiltration in the folds of the skin (behind the ears, on the neck, in the axillae and in the groin) with dissemination of scaly papular elements of a nummular character in the periphery of the foci (mild degree), which makes it necessary to differentiate dermatitis from psoriasis. In cases of moderate severity, the process extends beyond the boundaries of the skin folds, affecting significant areas of smooth skin on the scalp. The diaper area and axillary region may also be affected, with more pronounced erythema than scaling in these areas. Secondary bacterial and candidal infections may occur. It is characterized by erythema, infiltration, and scaling. Minor gastrointestinal disturbances are common, such as regurgitation 3-4 times per day and loose stools.

Leiner disease

The coalescence of foci leading to erythroderma is described as Leiner disease and is characterized by three main symptoms: generalized rash in the form of erythroderma with desquamation, diarrhea, and hypochromic anemia. Delayed development and absence of neutrophil chemotactic factor C5a are noted.

The disease typically develops immediately after birth, less frequently in individuals older than 1 month of age, with erythematous infiltrated foci of bright red color and abundant desquamation, mainly in skin folds (groin, axillary). In the perineal area, on the buttocks and in the skin folds, the skin becomes macerated, cracked and may ooze.

Greasy yellow scales on the scalp (cradle cap) spread to the eyebrow area and earlobes.

The overall condition of affected individuals is severe. Skin involvement is combined with gastrointestinal disturbances (frequent loose stools, vomiting), weight loss, hypotrophy, widespread candidal infection, and various infectious diseases. Without treatment, children develop severe toxic-septic conditions.

Adults:

• Psoriasis
• Pemphigus erythematosus
• Pemphigus foliaceus
• Allergic contact dermatitis
• Tinea faciei
• Tinea corporis, capitis
• Lupus Erythematosus
• Perioral Dermatitis
• Rosacea
• Acneiform Dermatoses
• Pityriasis Rosea
• Secondary Syphilis
• Large plaque Parapsoriasis

Infants:

• Atopic Dermatitis
• Scabies
• Langerhans Cell Histiocytosis
• Psoriasis
• Neonatal Lupus Erythematosus

General Remarks on Therapy

• The choice of treatment strategy depends on the severity of clinical manifestations, the duration of the disease, and the effectiveness of previously administered therapies.
• The condition requires regular treatment using systemic and topical therapies over an extended period.
• For topical treatment, medications with anti-inflammatory, antipruritic, antifungal properties are used.
• In acute stage with severe itching and sleep disturbances, antihistamines and sedatives are recommended.

Treatment Regimens

Topical Treatment

Topical Glucocorticosteroids

• Betamethasone valerate 0.1%, cream, ointment, applied once daily for 7-14 days, or
• Betamethasone dipropionate 0.025%, cream, ointment, applied once daily for 7-14 days, or
• Hydrocortisone butyrate 0.1%, cream, ointment, applied twice daily for 7-14 days, or
• Methylprednisolone aceponate 0.1%, cream, ointment, applied once daily for 7-14 days, or
• Mometasone furoate 0.1%, cream, ointment, applied once daily for 7-14 days.

Topical calcineurin inhibitors

• Tacrolimus 0.03%, 0.1% ointment, twice a day for up to 6 weeks, maintenance therapy - twice a week as needed.
• Pimecrolimus 1% cream, twice a day for up to 6 weeks, maintenance therapy - twice a week as needed.

Topical antifungals

Ketoconazole, bifonazole, and ciclopiroxolamine creams and shampoos may be used for treatment. Prophylactic use of ketoconazole helps maintain remission. Bifonazole and ciclopiroxolamine may be prescribed in shampoo form three times a week. The shampoo should be applied to the scalp and beard area. The application time is 5-10 minutes before rinsing. After remission is achieved, the frequency of shampoo use may be reduced to twice a week or as needed.

Subsequent treatment involves using low-potency topical glucocorticosteroids and pastes containing 2-3% tar, naphthalan oil, or 0.5-1% sulfur.

Systemic Therapy

For severe itching, antihistamines are recommended:

• Acrivastine 8 mg orally twice daily for 14-20 days, or
• Loratadine 10 mg orally once daily for 10-20 days, or
• Cetirizine 5 mg orally twice daily for 10-20 days.
• Fexofenadine 120-180 mg orally once daily for 10-20 days, or

Tactics in Case of Treatment Failure

In severe cases or resistance to topical therapy, oral antifungal drugs may be prescribed.

• Itraconazole 200 mg orally once daily for the first week of treatment, then 200 mg orally once daily for the first 2 days of each subsequent 2-11 months of treatment, or
• Terbinafine 250 mg orally once daily continuously for 4-6 weeks or 12 days per month continuously for 3 months, or
• Fluconazole 50 mg orally once daily for 2 weeks or 200-300 mg once weekly for 2-4 weeks, or
• Ketoconazole 200 mg orally once daily for 4 weeks.