The goal of seborrheic dermatitis therapy is to relieve the signs and symptoms and produce normal structure and function of the skin. Seborrheic dermatitis can significantly affect a patient's quality of life, so therapy aims to improve skin symptoms and life quality.

Topical therapy

Topical therapy aims to regulate sebum production, reduce colonization of M. furfur in the skin, and control inflammation. Topical management of seborrheic dermatitis is divided into scalp and non-scalp therapy.

A transverse multicenter epidemiological study on 2159 patients with seborrheic dermatitis on the face and scalp showed that the most commonly used therapies were:
  • topical steroids (59.9%), 
  • antifungal imidazole (35.1%),
  • topical calcineurin inhibitor (TCI) (27.2%), 
  • together with the use of a moisturizing or emollient product (30.7%).

Seborrheic dermatitis therapy of the scalp

Topical therapy is the first-line approach to the treatment of scalp seborrheic dermatitis. Topical therapies used are substances that have antifungal, sebum-regulating, keratolytic, and/or anti-inflammatory functions. These agents are available in various formulations such as creams, emulsions, foams, ointments, and shampoos. The use of medicated shampoo is 2 to 3 times a week, left for 5-10 minutes, to optimize its antifungal and keratolytic effect.

Ketoconazole is an azole antifungal that is fungistatic, fungicidal, and anti-inflammatory. It inhibits fungal growth by inhibiting lanosterol 14 demethylase, which inhibits ergosterol synthesis. Many studies have demonstrated its efficacy.6 An open randomized parallel-group study demonstrated the effectiveness of ketoconazole shampoo 2% better than 1% (p <0.001).

Seven double-blind randomized controlled trials analyzing evidence-based reviews showed good results in 88% of subjects treated with ketoconazole shampoo or cream. They have shown that ketoconazole shampoo's efficacy alternating with 0.05% clobetasol propionate shampoo combined was better than ketoconazole alone (p <0.05). The high safety profile of ketoconazole is supported by several studies based on minimal percutaneous absorption, low irritation, and sensitization potential.

Cyclopyroxolamine is a broad-spectrum antifungal agent that is a hydroxypyridone derivative. These agents inhibit the uptake and use of substances necessary to synthesize fungal cell membranes by changing their permeability. Cyclopyroxolamine also has anti-inflammatory properties because it blocks the release of prostaglandins and leukotrienes. Furthermore, in vitro studies have shown its activity in inhibiting the growth of gram-positive and negative microorganisms. 

In a multicentre, randomized, controlled, double-blind study, 178 patients received two or once Ciclopiroxolamina 0.77% gel or carrier only. At the end of the study, symptoms improved significantly in the Ciclopiroxolamina-treated group of patients compared with the control group (p <0.01).

Piroctone olamine is also known as octopirox and is useful in the treatment of fungal infections. Piroctone olamine is an active ingredient that can relieve scalp inflammation and reduce the skin's scaling by inhibiting fungus. Piroctone olamine can functionally interfere with yeast cell division and material transfer (inhibition of sodium-potassium channels) and inhibit fungal growth.

 Bisabolol or Butyrospermum parkii is commonly known as shea butter. This ingredient has anti-inflammatory and antifungal properties. However, bisabolol is less potent if given monotherapy. , so it is usually combined with other agents to treat seborrheic dermatitis.

Glycyrrhizic acid has anti-inflammatory, anti-irritant, anti-allergic, and antiviral properties. A randomized comparative clinical study on 67 subjects with seborrheic dermatitis of the scalp, shampoo containing glycyrrhizic acid plus Ciclopiroxolamina and zinc pyrithione was administered. After the administration of 3 times a week for two weeks, subjects were randomly assigned to receive the neutral shampoo once a week for 8 weeks. Significant improvement was observed during the therapy period (p <0.0001) with a decrease in symptoms of itching and skin peeling) as well as the presence of skin Malassezia. During the maintenance phase, the improvement was sustained only in the group that received maintenance therapy with significant differences between groups. 

Salicylic acid is a type of beta-hydroxy acid that can release hard and thick scales from the scalp through keratolytic activity, making it effective in treating seborrheic dermatitis.

 Tar has antifungal and anti-inflammatory properties. Several studies have shown its ability to reduce sebum. The in vitro fungistatic activity appears to be similar to that of ketoconazole. Tar shampoos are widely used, although the evidence for their efficacy is minimal.

 Zinc pyrithione, a fungistatic antifungal that works by increasing copper levels in fungal cells and damaging the iron-sulfur protein bonds, thereby disrupting fungal metabolism. Targeted Malassezia is found mainly in the follicular infundibulum. At the same time, this agent acts on the scalp's follicular infundibulum and remains on the hair follicle for up to 10 days.

 Corticosteroids are anti-inflammatory, immunosuppressive, and anti-proliferative. Therefore, they can inhibit the proliferation of keratinocytes and fibroblasts and cause vasoconstriction. The selecting corticosteroids are based on type, location, severity, and extent of disease and patient age. Corticosteroids are considered to be the first and second-line therapeutic approaches in the scalp and non-scalp seborrheic dermatitis. The main goal of treatment using corticosteroids is to rapidly control the signs and symptoms of seborrheic dermatitis, but data is limited. Relapses occur more rapidly and more frequently when using corticosteroids than with other antifungal agents and non-steroidal topical therapies.

The absorption, efficacy, and toxicity of topical corticosteroids vary depending on the area treated. In adults with moderate to severe scalp Seborrheic Dermatitis, with diffuse involvement, accompanied by burning and itching, moderate to strong potency corticosteroids alone or non-steroidal agents can be used. Seborrheic dermatitis on the face can be given weak to moderate potency Corticosteroids. Applying a non-irritating and moisturizing carrier is recommended. After improvement, applying corticosteroids can be reduced gradually, and non-steroidal agents can be added to prevent recurrence and relapse (maintenance therapy). 

Treatment of hairless seborrheic dermatitis

Several agents have been discussed in the therapy of seborrheic dermatitis of the scalp. In non-scalp seborrheic dermatitis, topical preparations are used in the form of creams, foams, and ointments. In a randomized controlled study conducted on 1162 patients, we evaluated ketoconazole's efficacy and tolerance of 2% cream and foam with a cream and foam carrier applied twice daily for 4 weeks.

Clinical improvement was seen in 56% of the therapy group and 42% of the control group. Furthermore, ketoconazole in the form of foam or cream was equally effective and well-tolerated. In comparison, a randomized and double-blind study on the efficacy of cyclopyroxolamine in 129 patients showed improvement in 63% of the treated group compared to 34% of the control group.

In a double-blind trial, 72 patients were given ketoconazole 2% cream (n = 63) or hydrocortisone 1% cream (n = 36) for 4 weeks. clinical responses in the ketoconazole group were 80.8% and 94.4% in the hydrocortisone group. There was no significant difference in symptoms of redness, peeling, itching, and papules between the two groups when the scores were added at weeks 2 and 4 compared with baseline scores. The incidence of side effects in both groups was also low.

Topical calcineurin inhibitors have immunomodulatory and anti-inflammatory properties, making them useful for the therapy of seborrheic dermatitis. Both are macrolide lactones that inhibit the enzyme calcineurin and suppress the release of proinflammatory cytokines.

Pimecrolimus inhibits the synthesis and release of proinflammatory cytokines from T lymphocytes and mast cell degranulation. Tacrolimus modulates T helper 2 response, inhibiting IL-2.6 transcription. 0.1% tacrolimus ointment was effective as the 1% hydrocortisone ointment in treating seborrheic dermatitis. It required less application over the 12 week study period as it relieves symptoms and is preferred by patients. A randomized trial compared  1% pimecrolimus cream with 0.1% betamethasone in 20 patients with seborrheic dermatitis. They were asked to discontinue therapy when symptoms had cleared up. On day 9, all patients had stopped therapy. The two drugs were equally effective in reducing erythema symptoms, peeling, and itching, but a longer period of remission was seen in the pimecrolimus group.