List of Abbreviations
ICD – International Classification of Diseases
Terms and Definitions
Seborrheic dermatitis is a chronic relapsing skin disease manifested by inflammation and desquamation of the skin in areas where sebaceous glands are concentrated. Seborrheic dermatitis is characterized by changes in the qualitative composition and amount of sebum, impaired epidermal barrier, and a defective immune response to skin colonization by Malassezia spp.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Seborrheic dermatitis is a chronic relapsing skin disease manifested by inflammation and desquamation of the skin in areas where sebaceous glands are concentrated. Seborrheic dermatitis is characterized by changes in the qualitative composition and amount of sebum, impaired epidermal barrier, and a defective immune response to skin colonization by Malassezia spp.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The exact causes of seborrheic dermatitis remain unclear. For a long time, lipophilic yeast-like fungi of the genus Malassezia spp. were considered the primary factor in the development of seborrheic dermatitis. It has been proven that patients with seborrheic dermatitis have an increased count of these yeast-like fungi compared to healthy individuals, but an increased number of Malassezia spp. alone is not sufficient to trigger the symptoms of seborrheic dermatitis. Currently, genetic characteristics related to sebaceous gland secretion, the epidermal barrier, and the host immune system have been identified. These factors promote excessive colonization by Malassezia spp. and the manifestation of inflammatory symptoms of seborrheic dermatitis on the skin in the presence of predisposing exogenous and endogenous factors (psychoemotional stress, neuroendocrine disorders, immunodeficiency, improper skin care, medication use, etc.) [1,2].
1.3 Epidemiology of the Disease or Condition
There are three peak ages of incidence: the period from 3 weeks to 3 months of age, puberty, and between 30 and 60 years. In the neonatal and infant periods, the prevalence of seborrheic dermatitis is up to 70%. According to various sources, the prevalence of seborrheic dermatitis in adults ranges from 3% to 20% (it is estimated that a mild form of scalp seborrheic dermatitis (dandruff) occurs in 15–20% of the population, though patients do not always seek medical attention) [3,4]. An increase in the number of patients suffering from seborrheic dermatitis is recorded among individuals with HIV infection, Parkinson's disease, alcoholic pancreatitis, hepatitis C, and depression [5,6,7].
1.4 Features of Coding the Disease or Condition
Seborrheic dermatitis (L21):
L21.0 – Seborrhea capitis. Cradle cap;
L21.1 – Seborrheic infantile dermatitis;
L21.8 – Other seborrheic dermatitis;
L21.9 – Seborrheic dermatitis, unspecified.
1.5 Classification of the disease or condition
Clinical forms of seborrheic dermatitis include:
Seborrheic dermatitis in adults:
Scalp seborrheic dermatitis;
Facial seborrheic dermatitis;
Truncal seborrheic dermatitis;
Generalized seborrheic dermatitis.
Seborrheic dermatitis in children:
Scalp seborrheic dermatitis ("cradle cap");
Truncal seborrheic dermatitis;
Leiner-Moussous disease (Leiner's erythroderma).
The severity of seborrheic dermatitis ranges from mild to severe and depends on the extent of the disease, the degree of inflammation and infiltration of skin lesions, and the intensity of pruritus.
1.6 Clinical presentation of the disease or condition
Rash elements in seborrheic dermatitis are located on the scalp, face, external auditory canal, upper trunk (predominantly in the sternal and scapular regions), and in major skin folds.
Scalp seborrheic dermatitis in adults:
In adults, scalp seborrheic dermatitis is most often mild and manifests solely as scaling without signs of inflammation (dandruff or pityriasis simplex), accompanied by mild to moderate itching that worsens as the scalp becomes soiled.
Scalp seborrheic dermatitis may manifest not only with desquamation but also with inflammatory lesions, most commonly macules and less frequently mildly infiltrated plaques with yellowish scales on the surface. In cases of severe inflammation, the scales become soaked with exudate, forming serous or seropurulent crusts. Inflammatory elements can coalesce and involve the entire scalp, extending to the forehead and retroauricular folds. Patients may experience significant pruritus.
Facial seborrheic dermatitis in adults.
On the face, rashes are typically symmetrical, localized in the central part of the forehead, nasolabial folds, alae nasi, glabella, eyebrows, beard area, external auditory canal, and retroauricular folds, and are frequently combined with scalp involvement. The rashes present as round or irregularly shaped erythematous patches; infiltration, scaling, and crusting may occur. The development of blepharitis leads to erythema along the ciliary margin of the eyelids, crusting along the eyelid margin, and an accumulation of cornified cells around the eyelashes.
Truncal seborrheic dermatitis in adults.
On the trunk (in the interscapular region and over the sternum) and in major skin folds, rashes present as sharply demarcated erythematous and erythematosquamous macules or plaques with a smooth, shiny surface, sometimes covered with yellowish scales; micro-papular elements may be present at the periphery. Skin folds are more prone to edema, oozing, and painful fissures. Secondary infection and the spread of bacterial infection beyond the primary skin lesions are possible [8,9].
Seborrheic dermatitis in children.
Seborrheic dermatitis occurs in 70% of infants during the first three months of life and in most cases represents a physiological skin feature in children, manifesting on the scalp or face as isolated yellowish crusts that are easily removed after moisturization, without erythema or pruritus.
Less commonly, infantile seborrheic dermatitis manifests as inflammatory rashes on the face and head (forehead, eyebrows, glabella, retroauricular folds), neck folds, axillary, inguinal, popliteal, and cubital folds, as well as the perianal and umbilical regions. The rashes are characterized by erythematous macules, less frequently slightly infiltrated plaques covered with yellowish scales or crust-scales; lesions in the folds are smooth and may be accompanied by oozing and fissures. Erythematous spots on the trunk may have irregular or oval outlines, satellite lesions may appear at the periphery of the main foci, and discrete rashes can coalesce. Rashes may be accompanied by pruritus of varying intensity [10].
A rapid coalescence of lesions leading to erythroderma is described as Leiner-Moussous disease and is characterized by three main symptoms: a generalized rash in the form of universal exfoliative erythroderma; diarrhea; and hypochromic anemia. Leiner's erythroderma typically develops in the neonatal period, less commonly after 1 month of age. According to modern concepts, Leiner's disease is associated with a congenital defect of the complement system (C3, C4, C5), leading to impaired immune defense in the patient. The condition is accompanied by a deterioration in the patient's general health, lymphadenopathy, and fever. Secondary infection may supervene. If Leiner-Moussous disease is suspected, hospitalization in a pediatric inpatient facility is required [11].
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis/condition: the diagnosis of seborrheic dermatitis is established based on the clinical manifestations of the disease.
2.1 Complaints and Anamnesis
It is recommended to take a history and gather complaints from all patients with suspected seborrheic dermatitis [12,13].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: Patients with seborrheic dermatitis complain of skin rashes, scaling on the scalp and face, which may be accompanied by varying degrees of pruritus.
Seborrheic dermatitis in children appears in the first months of life; in most cases, the rashes (scales, crusts) are limited in nature and do not affect the child's well-being.
In adults, the history should ascertain trigger factors for the development and relapse of seborrheic dermatitis (psychoemotional stress, neuroendocrine disorders, immunodeficiency, improper skin care, and medications taken for other conditions) [12,13].
2.2 Physical Examination
It is recommended to perform a physical examination of all patients with seborrheic dermatitis [12,13].
LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)
Comments: The mainstay of diagnosis is a visual inspection of the patient's skin and palpation. The nature of the rashes, their localization, and the degree of infiltration of the rash elements are assessed.
2.3 Laboratory Diagnostics
It is recommended in cases of Leiner-Moussous disease to assess the patient's condition [55]:
Complete blood count (CBC) with differential;
General general-therapeutic blood biochemistry test;
Urinalysis (general clinical urine test).
Level of Evidence CGrade of Recommendation 5Level of Evidence C (Level of Confidence 5)
It is recommended to perform a lifetime pathomorphological biopsy (surgical) material examination for morphological verification of the diagnosis when clinical diagnostics of seborrheic dermatitis is difficult [56].
GCR BLOCE 2Grade of Recommendation B (Level of Evidence 2)
Comments: In skin lesions of seborrheic dermatitis, a perivascular infiltrate composed of lymphocytes and histiocytes, along with moderate spongiosis, is detected. Follicular plugs due to orthokeratosis and parakeratosis, as well as clusters of neutrophils in the follicular infundibula, are found. Yeast cells can be visualized using specific stains.
2.4 Instrumental Diagnostics
It is recommended to perform magnified skin examination (dermoscopy) for differential diagnosis when the process is localized on the scalp in seborrheic dermatitis [14-16].
Comments: Yellow perifollicular scales, multiple thin branching vessels, and single-loop vessels.
GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)
2.5 Other Procedures
It is recommended to have an initial consultation (examination) by a pediatrician if Leiner-Moussous disease is suspected [55].
Level of Evidence CGrade of Recommendation 5Level of Evidence C (Level of Confidence 5)
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
Treatment of seborrheic dermatitis depends on many factors: skin lesion distribution, degree of inflammation, patient age, comorbidities, therapy side effects, etc.
In most cases, topical therapy is indicated, including medicinal products with anti-inflammatory, antifungal, and keratolytic effects. Systemic therapy may be necessary for widespread skin lesions, as well as in cases of topical therapy failure [17].
Treatment of seborrheic dermatitis in adults.
Treatment of seborrheic dermatitis of the scalp.
For mild seborrheic dermatitis (without erythematous rashes or with scanty erythematous rashes)
It is recommended to prescribe shampoos with antifungal and anti-inflammatory effects:
Ketoconazole medicinal shampoo 2% 2 times a week for 3-4 weeks, then 1 time in 1-2 weeks [18,19,22]
GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).
or Ciclopirox olamine shampoo 1.5% 2 times a week for 3-4 weeks, then 1 time in 1-2 weeks [20,22]
LeR ALoE 1Level of Evidence A (Level of Confidence of Evidence 1).
Comments: ciclopirox olamine shampoo is not classified as a medicinal product.
or #Sertaconazole medicinal shampoo 2% daily for 4 weeks, then 1 time a week [21]
GCR CLOE 4Grade of Recommendation C (Level of Evidence 4).
or Sertaconazole medicinal shampoo 2% 2 times a week for 2-4 weeks (according to the instructions for use) [22]
LeR ALoE 1Level of Evidence A (Level of Confidence of Evidence 1).
or Zinc pyrithione medicinal shampoo 1% – 3 times a week for 2 weeks, then – as needed [23-24].
Level of Recommendations B (Level of Evidence 2)Level of Evidence 2Level of Recommendations B (Level of Evidence 2).
or Selenium sulfide shampoo 2.5% 2 times a week for 2 weeks, then – as needed [25-26].
Level of Recommendations B (Level of Evidence 2)Level of Evidence 2Level of Recommendations B (Level of Evidence 2).
Comments: selenium sulfide shampoo is not classified as a medicinal product.
or Coal tar shampoo 2 times a week for 2 weeks, then – as needed [27,28].
GGR BLOC 3Grade of recommendation B (Level of evidence 3).
Comments: coal tar shampoo is not classified as a medicinal product
It is recommended for pronounced scalp inflammation to use a short course of anti-inflammatory treatment:
#Clobetasol 0.05% shampoo 2 times a week for 10-14 days [29].
Level of Recommendations B (Level of Evidence 2)Level of Evidence 2Level of Recommendations B (Level of Evidence 2).
Comments: a combination regimen of #Clobetasol 0.05% shampoo 2 times a week and ketoconazole 2% shampoo 2 times a week for 2 weeks is possible, followed by maintenance therapy with ketoconazole 2% shampoo 1 time a week for 2 weeks [29].
It is recommended for pronounced inflammation and scaling of the scalp to prescribe corticosteroids in combination with other agents:
Betamethasone 0.05% + salicylic acid 2%, solution – 2 times a day for no more than 3-4 weeks [30].
RG CLE 5Recommendation Grade C (Level of Evidence 5).
Comments: The ointment dosage form may be used.
or Zinc pyrithione 0.2% aerosol, 2 times a day topically for 10-14 days, then as needed [32].
GGR CLOC 2Grade of recommendation C (Level of evidence 2).
Comments: may be used in the cream dosage form.
Treatment of seborrheic dermatitis of the face and trunk
It is recommended to prescribe low-potency corticosteroids (group I):
Hydrocortisone** 1% ointment 1-2 times a day topically for 7-14 days [34,35].
GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).
It is recommended in case of inefficacy of low-potency corticosteroids to prescribe medium- and high-potency agents (WHO classes II-III):
Mometasone** 0.1% cream 1 time a day topically for 7-14 days [35,36].
GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).
or Betamethasone** 0.1% cream, ointment 1-2 times a day topically for 7-14 days [35, 37,38].
GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).
or Betamethasone** 0.05% spray for external use 2 times a day topically for 7-14 days [35].
GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).
Comments: Cream and ointment dosage forms may be used.
or Methylprednisolone aceponate 0.1%, emulsion for external use 1 time a day [31].
RG CLE 5Recommendation Grade C (Level of Evidence 5).
Comments: the use of corticosteroids for the treatment of seborrheic dermatitis is indicated for several days [13]. Cream and ointment dosage forms may be used in accordance with the indications and contraindications in the instructions for use.
#Methylprednisolone aceponate 0.1%, cream 2 times a day for up to 8 weeks [39].
GGR ALOC 2Grade of recommendation A (Level of evidence 2).
Comments: The ointment dosage form may be used.
It is recommended to prescribe non-corticosteroid drugs for the treatment of dermatitis:
#Pimecrolimus** 1% cream, 2 times a day for up to 6 weeks, maintenance therapy – 2 times a week as needed [35,40,44].
GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).
or #Tacrolimus** 0.1% ointment 2 times a day for 2 weeks, then as needed 1-2 times a day for no more than 12 weeks [35]
GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).
It is recommended to prescribe topical antifungal drugs:
Ciclopiroxolamine 1% cream 2 times a day topically for 14-28 days, then as needed [22,42,43].
GGR ALOC 2Grade of recommendation A (Level of evidence 2).
or Ketoconazole 2% cream 2 times a day topically for 14-28 days, then as needed [22].
GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).
or #Clotrimazole 1% cream, solution 1-2 times a day for 10-14 days, then as needed [22].
LeR ALoE 1Level of Evidence A (Level of Confidence of Evidence 1).
or #Sertaconazole 2% cream, 2 times a day for 4 weeks [57,58].
Level of Recommendations B (Level of Evidence 2)Level of Evidence 2Level of Recommendations B (Level of Evidence 2).
or Zinc pyrithione 0.2% cream 2 times a day topically for 10-14 days, then as needed [32].
GGR BLOC 2Grade of recommendation B (Level of evidence 2).
For adult patients with widespread rashes and severe seborrheic dermatitis:
It is recommended to perform selective phototherapy 3 times a week for no more than 8 weeks [44].
GCR CLOE 4Grade of Recommendation C (Level of Evidence 4).
In case of resistance to topical therapy and a large affected area
It is recommended to prescribe systemic antifungal drugs:
#Itraconazole 200 mg orally 1 time a day during the first week of treatment, then 200 mg orally 1 time a day during the first 2 days of the subsequent 2-11 months of treatment [45,46].
GPR BLEL 2Grade of Recommendation B (Level of Evidence 2).
or #Terbinafine 250 mg orally 1 time a day continuously for 4-6 weeks or 12 days a month continuously for 3 months [47,49].
Level of Recommendations B (Level of Evidence 2)Level of Evidence 2Level of Recommendations B (Level of Evidence 2).
or #Fluconazole** 50 mg orally 1 time a day for 2 weeks or 300 mg 1 time a week for 2 weeks [48].
GGR BLOC 2Grade of recommendation B (Level of evidence 2).
or #Ketoconazole 200 mg orally 1 time a day for 4 weeks [45,49].
GGR BLOC 2Grade of recommendation B (Level of evidence 2).
Recommended are retinoid medications for the treatment of acne vulgaris:
#Isotretinoin 10 mg orally 1 time a day every other day for up to 6 months [59].
GPR BLEL 2Grade of Recommendation B (Level of Evidence 2)
Treatment of seborrheic dermatitis in children.
A Cochrane systematic review on the treatment of infantile seborrheic dermatitis published in March 2019 revealed a lack of studies meeting evidence-based medicine requirements regarding seborrheic dermatitis in children [50].
It is recommended for the treatment of uncomplicated forms of seborrheic dermatitis in children: warm olive oil compresses, and proper skin care [13].
RG CLE 5Recommendation Grade C (Level of Evidence 5).
Comments: In most cases, the treatment of seborrheic dermatitis in children is limited to prescribing proper skin care. If there are scales and crusts without signs of inflammation on the scalp, eyebrows, or retroauricular folds, mineral or vegetable oils (olive, peach, burdock, etc.) or cosmetic products intended for children's skin care may be used.
Hydrocortisone** 1% ointment 1–2 times a day for 5–7 days, approved for use from 2 years of age [31].
RG CLE 5Recommendation Grade C (Level of Evidence 5).
or Methylprednisolone aceponate 0.1% emulsion, 1 time a day, approved for use from 4 months of age [31].
RG CLE 5Recommendation Grade C (Level of Evidence 5).
Comments: the use of corticosteroids for the treatment of seborrheic dermatitis in children is indicated for several days [13]. Cream and ointment formulations may be used in accordance with the indications and contraindications of the package insert.
It is recommended for the treatment of seborrheic dermatitis in children in intertriginous areas:
Ketoconazole 2% cream 1 time a day for 2–4 weeks, then as needed [53-54].
GCR CLOE 4Grade of Recommendation C (Level of Evidence 4).
Recommended for Leiner-Moussier disease: initial pediatric consultation (examination) and hospitalization of the child in a pediatric inpatient department [55].
RG CLE 5Recommendation Grade C (Level of Evidence 5).
3.2 Surgical Treatment
Not applicable.
3.3 Other Treatment
Diet therapy is not used.
Pain management is not used.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not required.
5. Prevention and Dispensary Observation
Methods for the prevention of seborrheic dermatitis have not been developed.
6. Organization of Medical Care
Indications for inpatient treatment:
Severe widespread seborrheic dermatitis.
Lack of response to ongoing outpatient treatment
Patients with Leiner-Moussier disease (Leiner's erythroderma) are hospitalized in a pediatric inpatient facility.
Indications for patient discharge from a medical organization:
- regression of rashes and/or reduction of clinical manifestations.
7. Additional Information
No.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance assessment |
1. | Topical antifungal therapy was administered | Yes/No |
2. | Low-potency corticosteroid therapy or medium- and high-potency corticosteroid therapy was administered | Yes/No |
3. | Therapy with shampoos having antifungal and anti-inflammatory effects was administered | Yes/No |
4. | Therapy with drugs for dermatitis other than corticosteroids was performed | Yes/No |
5. | Systemic antifungal therapy was performed | Yes/No |
6. | Reduction in the severity of erythema, scaling, and the number of crusts in the affected areas was achieved | Yes/No |
References
Show references
1. Clark GW, Pope SM, Jaboori KA Diagnosis and treatment of seborrheic dermatitis. Am Fam Physician. 2015 Feb 1; 91(3):185-90.
2. Schwartz JR, Messenger AG, Tosti A, Todd G, Hordinsky M, Hay RJ, Wang X, Zachariae C, Kerr KM, Henry JP, Rust RC, Robinson MK comprehensive pathophysiology of dandruff and seborrheic dermatitis - towards a more precise definition of scalp health. Acta DermVenereol. 2013 Mar 27; 93(2):131-7.
3. Schwartz RA, Janusz CA, Janniger CK. Seborrheic dermatitis: an overview. Am Fam Physician. 2006;74(1):125–30.
4. Choeng WK, Yeung CK, Torsekar RG, Suh DH, Ungpakorn R, Widaty S, et al. Treatment of seborrhoeic dermatitis in Asia: a consensus guide. Skin Appendage Disord. 2015;1:187–96
5. Chatzikokkinou P, Sotiropoulos K, Katoulis A, Luzzati R, Trevisan G. Seborrheic dermatitis—an early and common skin manifestation in HIV patients. ActaDermatovenerolCroat ADC. 2008;16(4):226–30.
6. Cribier B, Samain F, Vetter D, Heid E, Grosshans E. Systematic cutaneous examination in hepatitis C virus infected patients. ActaDermVenereol. 1998;78(5):355–7.20.
7. Barba A, Piubello W, Vantini I, Caliari S, Cocchetto R, Vallaperta P, et al. Skinlesionsinchronicalcoholicpancreatitis. Dermatologica. 1982;164(5):322–6.
8. BukvićMokos Z, Kralj M, Basta-Juzbašić A, LakošJukić I Seborrheic dermatitis: an update. ActaDermatovenerol Croat. 2012; 20(2):98-104.
9. Clark GW, Pope SM, Jaboori KA Diagnosis and treatment of seborrheic dermatitis. AmFamPhysician. 2015 Feb 1; 91(3):185-90.
10. Sampaio AL, Mameri AC, Vargas TJ, Ramos-e-Silva M, Nunes AP, Carneiro SC Seborrheic dermatitis. AnBrasDermatol. 2011 Nov-Dec; 86(6):1061-71; quiz 1072-4.
11. Renee Howard Leiner's syndrome: Erythroderma, diarrhea, and failure to thrive Current Problems in Dermatology Volume 12, Issue 4, July–August 2000, Pages 183-185
12. Hald M, Arendrup MC, Svejgaard EL, Lindskov R, Foged EK, et al. Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases. ActaDermVenereol. 2015;95:12–19
13. Rodionov A.N., Zaslavsky D.V., Sydikov A.A. Dermatology: Illustrated Guide to Clinical Diagnostics by Professor A.N. Rodionov, 2018; P. 944
14. Kim GW, Jung HJ, Ko HC, et al. Dermoscopy can be useful in differentiating scalp psoriasis from seborrheic dermatitis. Br J Dermatol. 2011;164(3):652–656.
15. MelikeKibar, Şebnem Aktan,1 and MuzafferBilginDermoscopic Findings in Scalp Psoriasis and Seborrheic Dermatitis; Two New Signs; Signet Ring Vessel and Hidden Hair Indian J Dermatol. 2015 Jan-Feb; 60(1): 41–45.
16. SezinFicicioglu, Suleyman Piskin Dermoscopic findings in psoriasis and seborrheic dermatitis on the scalp and correlation with disease severity Medicine Science 2018;7(1):118-21
17. Abbas Z, Ghodsi SZ, Abedeni R. Effect of itraconazole on the quality of life in patients with moderate to severe seborrheic dermatitis: a randomized, placebo-controlled trial. DermatolPract Concept. 2016;6(3):11–6.
18. Apasrawirote W1, Udompataikul M, RattanamongkolgulS Topical antifungal agents for seborrheic dermatitis: systematic review and meta-analysis. J Med Assoc Thai. 2011 Jun;94(6):756-60.
19. Pierard-Franchimont C, Goffin V, Decroix J, Pierard GE. A multicenter randomized trial of ketoconazole 2% and zinc pyrithione 1% shampoos in severe dandruff and seborrheic dermatitis. Skin PharmacolAppl Skin Physiol. 2002;15:434–441.
20. Ratnavel RC, Squire RA, Boorman GC. Clinical efficacies of shampoos containing ciclopiroxolamine (1.5%) and ketoconazole (2.0%) in the treatment of seborrhoeic dermatitis. J Dermatolog Treat 2007; 18: 88–96.
21. Kruglova L.S., Markelova E.S. Seborrheic dermatitis of the scalp: from pathogenesis to rational treatment. Effective Pharmacotherapy. 2022; 18 (31): 16–20.
22. Okokon EO, Verbeek JH, Ruotsalainen JH, Ojo OA, Bakhoya VN. Topical antifungals for seborrhoeic dermatitis. Cochrane Database Syst Rev. 2015;5
23. Hald M, Arendrup MC, Svejgaard EL, Lindskov R, Foged EK, et al. Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases. ActaDermVenereol. 2015;95:12–19
24. Pierard-Franchimont C, Goffin V, Decroix J, Pierard GE. A multicenter randomized trial of ketoconazole 2% and zinc pyrithione 1% shampoos in severe dandruff and seborrheic dermatitis. Skin PharmacolAppl Skin Physiol. 2002;15:434–441
25. Danby FW, Maddin WS, Margesson LJ, Rosenthal D. A randomized, double-blind, placebo-controlled trial of ketoconazole 2% shampoo versus selenium sulfide 2.5% shampoo in the treatment of moderate to severe dandruff. J Am AcadDermatol 1993; 29: 1008–1012.
26. Gilbertson K, Jarrett R, Bayliss SJ, Berk DR. Scalp discoloration from selenium sulfide shampoo: a case series and review of the literature. PediatrDermatol. 2012;29:84–88
27. Juan Jorge Manríquez and Pablo Uribe Seborrhoeic dermatitis BMJ ClinEvid. 2007; 2007: 1713.
28. Davies DB, Boorman GC, Shuttleworth D. Comparative efficacy of shampoos containing coal tar (4.0% w/w; Tarmed™), coal tar (4.0% w/w) plus ciclopiroxolamine (1.0% w/w; Tarmed™ AF) and ketoconazole (2.0% w/w; Nizoral™) for the treatment of dandruff/seborrhoeic dermatitis. J Dermatolog Treat. 2009;10:177–183
29. Ortonne JP, Nikkels AF, Reich K, Ponce Olivera RM, Lee JH, Kerrouche N, et al. Efficacious and safe management of moderate to severe scalp seborrhoeic dermatitis using clobetasol propionate shampoo 0·05% combined with ketoconazole shampoo 2%: A randomized, controlled study. Br J Dermatol. 2011;165:171–6. doi: 10.1111/j.1365-2133.2011.10269.x
30. Belousova T.A. Modern principles of external therapy for inflammatory dermatoses. RMJ. 2008; 8: 547
31. Adaskevich V.P. Topical corticosteroids in the treatment of skin diseases // Vestnik farmacii. – 2006. – No. 3 (33). – P. 75-81.
32. Sheklakova M.N. Evaluation of the effectiveness of the new zinc pyrithione preparation Cynocap® in the treatment of patients with seborrheic dermatitis. Vestn Dermatol Venerol 2010; 3: 49–55
33. Opdyke DL, Burnett CM, Brauer EW anti-seborrhoeic qualities of zinc pyrithione in a cream vehicle. II. Safety evaluation. Food CosmetToxicol. 1967 Aug; 5(3):321-6.
34. Papp KA, Papp A, Dahmer B, Clark CS Single-blind, randomized controlled trial evaluating the treatment of facial seborrheic dermatitis with hydrocortisone 1% ointment compared with tacrolimus 0.1% ointment in adults.J Am AcadDermatol. 2012 Jul; 67(1):e11-5.c
35. Kastarinen H, Oksanen T, Okokon EO, Kiviniemi VV, Airola K, Jyrkka¨ J, et al. Topical anti-inflammatory agents for seborrheic dermatitis of the face or scalp. Cochrane Database Syst Rev.2014;5
36. Medansky R, Lepaw M, Shavin J, Zimmerman E, Jones M, Peets E, et al. Mometasonefuroate cream 0.1 % vs. hydrocortisone cream 1 % in the treatment of seborrheic dermatitis. J Dermatol Treat. 1992;3:125–8.
37. Milani M1, Antonio Di Molfetta S, Gramazio R, Fiorella C, Frisario C, Fuzio E, Marzocca V, Zurilli M, Di Turi G, Felice G Efficacy of betamethasone valerate 0.1% thermophobic foam in seborrhoeic dermatitis of the scalp: an open-label, multicentre, prospective trial on 180 patients. Curr Med Res Opin. 2003;19(4):342-5.
38. Rigopoulos D, Ioannides D, Kalogeromitros D, Gregoriou S, Katsambas A Pimecrolimus cream 1% vs. betamethasone 17-valerate 0.1% cream in the treatment of seborrhoeic dermatitis. A randomized open-label clinical trial. Br J Dermatol. 2004 Nov; 151(5):1071-5.
39. Cicek D1, Kandi B, Bakar S, Turgut D. Pimecrolimus 1% cream, methylprednisolone aceponate 0.1% cream and metronidazole 0.75% gel in the treatment of seborrhoeic dermatitis: a randomized clinical study. J Dermatolog Treat. 2009;20(6):344-9.
39. Warshaw EM, Wohlhuter RJ, Liu A, Zeller SA, Wenner RA, Bowers S, et al. Results of a randomized, double-blind, vehicle controlled efficacy trial of pimecrolimus cream 1 % for the treatment of moderate to severe facial seborrheic dermatitis. J Am AcadDermatol. 2007;57(2):257–64.
40. Kim T-W, Mun J-H, Wa S-WJ, Song M, Kim H-S, Ko H-C, et al. Proactive treatment of adult facial seborrheic dermatitis with 0.1 % tacrolimus ointment: randomized, double-blind, vehicle controlled, multi-center trial. ActaDermVenereol. 2013;93:557–61.
41. Unholzer A, Schinzel S, Nietsch K-H, Jung GE, Korting HC. Ciclopiroxolamine cream 1 % in the treatment of seborrheic dermatitis: a double-blind, parallel-group comparison with ketoconazole and vehicle in a confirmatory trial. Clin Drug Invest. 2002;22(3):167–72.
42. Aditya K. Gupta, Sarah G. VersteegTopical Treatment of Facial Seborrheic Dermatitis: A SystematicReviewAm J ClinDermatol2017 Apr;18(2):193-213
43. Pirkhammer D., Seeber A., Honigsmann H., Tanew A. Narrow-band ultraviolet B (ATL-01) phototherapy is an effective and safe treatment option for patients with severe seborrhoeic dermatitis. Br J Dermatol 2000; №143 (5): 964–968.
44. Gupta AK, Richardson M, Paquet M: Systematic review of oral treatments for seborrheic dermatitis. J EurAcadDermatolVenereol 2014;28:16-26.
45. Ghodsi SZ, Abbas Z, Abedeni R. Efficacy of oral itraconazole in the treatment and relapse prevention of moderate to severe seborrheic dermatitis: a randomized, placebo-controlled trial. Am J ClinDermatol. 2015; №16 (5): 431–437.
46. Scaparro E., Quadri G., Virno G. et al. Evaluation of the efficacy and tolerability of oral terbinafine (Daskil®) in patients with seborrhoeic dermatitis. A multicentre, randomized, investigator-blinded, placebo-controlled trial. Br J Dermatol 2001; №144 (4): 854–857.
47. Cömert A., Bekiroglu N., Gürbüz O., Ergun T. Efficacy of oral fluconazole in the treatment of seborrheic dermatitis: a placebo-controlled study. Am J ClinDermatol 2007; №8 (4): 235–238.
48. Gupta AK, Bluhm R. Seborrheic dermatitis. J EurAcadDermatolVenereol. 2004;18:13–26.
49. Victoire A, Magin P, Coughlan J, van Driel ML Treatments for infantile seborrhoeic dermatitis (including cradle cap), an inflammatory, scaly skin condition Cochrane Systematic Review - Intervention Version published: 04 March 2019
50. Levina, Yu. G., Namazova-Baranova, L. S., Efendieva, K. E., Alekseeva, A. A., Vishnyova, E. A., Kalugina, V. G., & Arimova, P. S. (2019). Use of topical glucocorticosteroids in the treatment of dermatites in children. Current Pediatrics, 18(5), 380-385.
51. Wannanukul S1, ChiabunkanaJ.Comparative study of 2% ketoconazole cream and 1% hydrocortisone cream in the treatment of infantile seborrheic dermatitis J Med Assoc Thai. 2004 Sep;87Suppl 2:S68-71.
52. Taieb A, Legrain V, Palmier C, Lejean S, Six M, Maleville J. Topical ketoconazole for infantile seborrhoeic dermatitis. Dermatologica 1990; 181: 26–32
53. Hald M, Arendrup MC, Svejgaard EL, Lindskov R, Foged EK, et al. Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases. ActaDermVenereol. 2015;95:12–19
54. Sauer, Gordon C.; Hall, John C. (1996). "Leiner's Disease". Manual of Skin Diseases (7th ed.).
55. Ji-Hye Park, Young Joon Park, [...], and You Chan Kim Ann Dermatol. 2016 Aug; 28(4): 427–432 Histopathological Differential Diagnosis of Psoriasis and Seborrheic Dermatitis of the Scalp
56. Azizzadeh M., Pahlevan D., Bagheri B. The Efficacy and Safety of Pimecrolimus 1% Cream vs. Sertaconazole 2% Cream in the Treatment of Patients with Facial Seborrhoeic Dermatitis: A Randomized Blinded Trial. Clin. Exp. Dermatol. 2022;47:926–931.
57. Georgescu SR, Mitran CI, Mitran MI, Amuzescu A, Matei C, Tampa M. A Meta-Analysis on the Effectiveness of Sertaconazole 2% Cream Compared with Other Topical Therapies for Seborrheic Dermatitis. J Pers Med. 2022 Sep 19;12(9):1540. doi: 10.3390/jpm12091540. PMID: 36143325; PMCID: PMC9501484.
58. De Souza Leão Kamamoto, C., Sanudo, A., Hassun, K. M., &Bagatin, E. (2016). Low-dose oral isotretinoin for moderate to severe seborrhea and seborrheic dermatitis: a randomized comparative trial. International Journal of Dermatology, 56(1), 80–85
Appendix A1. Working Group Composition
Alexey A. Kubanov – Academician of the RAS, President of the All-Russian Society of Dermatovenerologists and Cosmetologists (AOSDC), Director of the State Research Center of Dermatovenereology and Cosmetology of the Russian Ministry of Health;
Tatiana A. Sysoeva – Candidate of Medical Sciences, Member of the Russian Society of Dermatovenerologists and Cosmetologists;
Denis V. Zaslavsky – Doctor of Medical Sciences, Professor, Member of the Russian Society of Dermatovenerologists and Cosmetologists;
Vadim V. Chikin – Doctor of Medical Sciences, Member of the Russian Society of Dermatovenerologists and Cosmetologists;
Conflict of interest:
The authors declare no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Medical specialists: dermatovenereologists
Residents and trainees of continuing professional education programs in the specified specialty.
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing levels of evidence (LE) for methods of prevention, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)
LoE | Definition |
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for evaluating the levels of recommendation certainty (LRC) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural healing factors (preventive, diagnostic, therapeutic, and rehabilitation interventions)
GoR | Definition |
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The clinical guidelines update mechanism provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Medical care for patients with seborrheic dermatitis is provided by dermatovenerologists in accordance with the Procedure for the Provision of Medical Care in the Profile of "Dermatovenerology", approved by Order of the Russian Ministry of Health No. 924n dated November 15, 2012, "On Approval of the Procedure for the Provision of Medical Care to the Population in the Profile of 'Dermatovenerology'".
Appendix B. Physician Action Algorithms
Flowchart 1. Algorithm of physician actions in the management of pediatric patients with seborrheic dermatitis.
Flowchart 2. Algorithm of physician actions in the management of adult patients with seborrheic dermatitis of the face and trunk.
Flowchart 3. Algorithm of physician actions in the management of adult patients with seborrheic dermatitis of the scalp or widespread rashes.
Appendix C. Patient Information
Seborrheic dermatitis is a chronic relapsing skin disease.
The term "seborrheic" means that the disease affects areas with a high density of sebaceous glands (scalp, face, interscapular region, sternal region).
Risk factors for the development and recurrence of seborrheic dermatitis include:
psychoemotional stress
improper skin care
HIV infection
Parkinson's disease
alcoholic pancreatitis
hepatitis C
depression
use of certain medications
The diagnosis is established after a visual examination (fungal scraping and skin biopsy are not required in most cases)
For the treatment of seborrheic dermatitis, preparations (creams and shampoos) that suppress Malassezia spp. yeasts are most frequently used. Some of these preparations can be used long-term. Therapeutic shampoo should be applied to wet hair followed by scalp massage, then the hair should be rinsed, shampoo reapplied and left on the head for 5 minutes, and then thoroughly rinsed with plenty of water.
Hormonal creams are used only as prescribed by a physician and for short periods of time (no more than 14 days).
Carrying out treatment in accordance with the physician's recommendations in most cases leads to sustained improvement, but the disease tends to relapse; therefore, maintenance therapy is required after active treatment.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not applicable.