Seborrheic Dermatitis

Rick Lin, DO MPH

Texas Division
KCOM Dermatology Residency
Program
BACKGROUND
Seborrheic dermatitis is a papulosquamous
disorder
patterned on the sebum-rich areas of the
scalp, face and trunk.
linked to Pityrosporum ovale
immunologic abnormalities and activation of
complement.
aggravated by changes in humidity, by
trauma (scratching), seasonal change and by
emotional stress.
BACKGROUND
Severity varies from mild dandruff to
exfoliative erythroderma.
Seborrheic dermatitis may worsen in
Parkinson disease and in AIDS.
BACKGROUND
Seborrheic dermatitis is associated with
normal levels of Pityrosporum ovale, but
an abnormal immune response.
The contribution of P. ovale may come
from its lipase activity—releasing
inflammatory free fatty acids (FFA)—
and from its ability to activate the
alternative complement pathway.
BACKGROUND
Frequency: Incidence is 3-5% with a
worldwide distribution.
Race: Seborrheic dermatitis occurs in all
races.
Sex: The condition is slightly worse in males.
Age: The usual onset occurs with puberty. It
peaks at age 40 years and is less severe, but
present, among older people. In the infant it is
seen as cradle cap or uncommonly as a
flexural eruption or erythroderma.
History
Intermittent active phases present with
burning, scaling and itching, alternating with
inactive periods.
Increased activity is seen in winter and early
spring, with summer remissions common.
Active phases may be complicated by
secondary infection in the intertriginous areas
and on the eyelids.
History
Generalized seborrheic erythroderma is
rare. It is more often seen in AIDS,
CHF, Parkinson disease, and in
immunocompromised premature
infants.
Physical Exam
Scalp appearance varies from mild,
patchy scaling to widespread thick
adherent crusts. Plaques are rare.
From the scalp, seborrheic dermatitis
can spread onto the forehead, posterior
neck and postauricular skin, like
psoriasis.
Physical Exam
Skin lesions present as branny or
greasy scale over red, inflamed skin.
Hypopigmentation is seen in blacks.
Infectious eczematoid dermatitis, with
its oozing and crusting, suggests
secondary infection.
A seborrheic blepharitis may occur
independently.
Physical Exam
Distribution follows the oily and hair-bearing
areas of head and neck, such as the scalp,
forehead, eyebrows, lash line, nasolabial
folds, beard and postauricular skin.
Presternal or interscapular involvement is
more common than the nonscaling intertrigo
of the umbilicus, axillae, inframammilae
inguinal fold, perineum or anogenital crease
that may also be present.
Physical Exam
Two distinct truncal patterns can
occasionally occur.
A rare pityriasiform variety can be seen
on the trunk and neck, with peripheral
scaling around ovoid patches mimicking
pityriasis rosea.
Physical Exam
Pityrosporum is probably not the cause, but a
cofactor, linked to a T cell depression,
increased sebum and an activation of the
alternative complement pathway.
As seborrheic dermatitis is uncommon in
preadolescent childhood, and tinea capitis is
uncommon after adolescence, dandruff in a
child is more likely to represent a fungal
infection. A fungal culture should be done to
confirm this. (Age 6-15)
Differential Diagnosis
Asteatotic Eczema
Atopic Dermatitis
Candidiasis, Cutaneous
Contact Dermatitis, Allergic
Contact Dermatitis, Irritant
Dermatomyositis
Drug Eruptions
Drug-Induced Photosensitivity
Differential Diagnosis
Erythrasma
Extramammary Paget Disease
Impetigo
Intertrigo
Lichen Simplex Chronicus
Lupus Erythematosus, Acute
Nummular Dermatitis
Differential Diagnosis
Pemphigus Foliaceus
Perioral Dermatitis
Pityriasis Rosea
Rosacea
Tinea Capitis
Tinea Corporis
Tinea Cruris
Tinea Versicolor
Tests
A clinical diagnosis of seborrheic
dermatitis is usually made by a history
of waxing and waning severity and by
the distribution of involvement on exam.
A skin biopsy may be needed in
exfoliative erythroderma, and a fungal
culture can rule out tinea capitis.
Dermatopathology
Dermatopathology of seborrheic dermatitis is
nonspecific.
Hyperkeratosis, acanthosis, accentuated rete
ridges, focal spongiosis, and parakeratosis
are characteristic.
Psoriasis is distinguished by regular
acanthosis, thinned rete ridges,parakeratosis,
and an absence of spongiosis. Neutrophils
may be seen in both diseases.
Medical Care
Early treatment of flares is encouraged.
2 1/2% selenium sulfide or Nizoral
(ketoconazole) shampoos may help by
reducing Pityrosporum ovale scalp reservoirs.
Shampoos may be used on truncal lesions or
in beards but may inflame intertriginous or
facial involvement.
Neutrogena T-gel
Locoid solution.
Conclusion
Seborrheic Dermatitis mimic other
papulosquamous diseases. It can look like
many things
Fulminant Seborrheic Dermatitis requires
additional evaluation of the
immunosuppression status of the patient.
Referral to dermatologist if it just doen’t
“look right”
The End