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Seborrheic Dermatitis

Alexander K. C. Leung, Barankin B (2015) Seborrheic Dermatitis. Int J Pediat Health Care Adv. 2(1), 7-9. 7
International Journal of Pediatric Health Care & Advancements (IJPA)
IISSN 2572-7354
Seborrheic Dermatitis
Review Article
Alexander K. C. Leung1*, Barankin B2
1 Clinical Professor of Pediatrics, University of Calgary, Pediatric Consultant, Alberta Children's Hospital, Canada.
2 Dermatologist, Medical Director and Founder, Toronto Dermatology Centre, Canada.
*Corresponding Author:
Alexander K. C. Leung MBBS, FRCPC, FRCP(UK & Irel), FRCPCH,
Clinical Professor of Pediatrics, University of Calgary, Pediatric Consult-
ant, Alberta Children's Hospital, #200, 233 – 16th Avenue NW Calgary,
Alberta, Canada T2M 0H5, Canada.
Fax: (403) 230-3322
Received: June 01, 2015
Accepted: July 22, 2015
Published: July 24, 2015
Citation: Alexander K. C. Leung, Barankin B (2015) Seborrheic Derma-
titis. Int J Pediat Health Care Adv. 2(1), 7-9.
Copyright: Alexander K. C. Leung© 2015. This is an open-access ar-
ticle distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution and reproduction in
any medium, provided the original author and source are credited.
Seborrheic dermatitis is a common chronic inammatory skin
disease characterized by erythema and greasy scales [1]. The con-
dition typically affects areas rich in sebaceous glands such as the
scalp, eyebrows, glabella, nasolabial folds, postauricular area, and
intertriginous areas [2, 3]. In general, scaling tends to predominate
on the scalp whereas erythema tends to predominate in the ex-
ural folds and intertriginous areas [4].
Seborrheic dermatitis has two incidence peaks, the rst in the rst
three months of life and the second beginning at puberty, reach-
ing its apex at 30 to 40 years of age [5-7]. The condition affects
up to 70% of infants in the rst 3 months of life [3, 5] and 3 to
5% of young adults [7-9]. Seborrheic dermatitis is more common
in males than females, presumably because androgens stimulate
sebum production [6, 8].
Seborrheic dermatitis might result from excessive sebaceous
gland activity with sebum overproduction as the dermatitis usu-
ally develop in areas with the highest density of these glands [1].
The high prevalence of infantile seborrheic dermatitis in early in-
fancy can be explained by a transient surge of gonadotropins with
a resulting rise in testosterone levels which peaks at 1 to 3 months
of age. It is believed that the sebum permits growth and prolifera-
tion of commensal yeasts of the Malassezia (formerly known as
Pityrosporum) family which, through the action of lipases, degrade
lipids on the skin surface with production of unsaturated and
saturated fatty acids [7, 9]. The inammation which causes hy-
perproliferation of stratum corneum (scaling) results from non-
immunogenic irritation due to unsaturated fatty acids and the cel-
lular immune response to these yeasts [2, 7, 9]. There is a genetic
predisposition; there is an increase in the frequency of HLA-A32,
HLA-AW30, HLA-AW31, HLA-B12, and HLA-B18 in patients
Seborrheic dermatitis is a common chronic inammatory skin disease characterized by erythema and greasy scales affecting
areas rich in sebaceous glands. Seborrheic dermatitis has two incidence peaks, the rst in the rst three months of life and
the second beginning at puberty, reaching its apex at 30 to 40 years of age. Infants with seborrheic dermatitis often present
with focal or diffuse scaling and crusting of the scalp. Erythematous or salmon-colored sharply demarcated patches with
yellow-white scales may involve the face, postauricular areas, trunk, and intertriginous and exural areas of the body. In the
diaper area, infantile seborrheic dermatitis presents as a sharply demarcated, erythematous, scaly eruption with a tendency
to coalesce, resulting in the formation of a large conuent lesion. Pruritus is characteristically absent. In adolescence and
beyond, seborrheic dermatitis usually presents as greasy scaling of the scalp. It may also present as ill-dened erythema-
tous patches with yellow-white, greasy scales affecting the nasolabial folds, eyelids, eyebrows, glabella, postauricular area,
anterior chest, and less commonly the upper back. Mild periodic pruritus is common in adolescent seborrheic dermatitis.
Scalp lesions in infantile seborrheic dermatitis usually respond to simple daily shampooing alone or in combination with
non-prescription mild shampoos specic for seborrheic dermatitis. For infantile scalp seborrheic dermatitis that does not
respond to the above measures, for seborrheic dermatitis lesions elsewhere, and for adolescent or adult seborrheic derma-
titis, the use of topical antifungals, calcineurin inhibitors, and low to mid potency corticosteroids should be considered. A
compounded mixture of these ingredients is also often employed.
Keywords: Erythema; Greasy Scales; Cradle Cap; Diaper Rash; Topical Antifungals.
Alexander K. C. Leung, Barankin B (2015) Seborrheic Dermatitis. Int J Pediat Health Care Adv. 2(1), 7-9. 8
with seborrheic dermatitis [7, 9].
In adolescence and beyond, predisposing factors include HIV
infection, stress, medications (haloperidol, chlorpromazine, bus-
pirone, lithium), trisomy 21, and familial amyloidosis with poly-
neuropathy [3, 5, 6].
Histological ndings in the acute stage include spongiosis, focal
parakeratosis, plugged follicular ostia, and supercial perivascular
and interstitial lymphocytic inltration [2, 7]. In the chronic stage,
changes include in addition to the aforementioned ndings, ir-
regular acanthosis, a poorly formed or absent granular layer, and
psoriasiform hyperplasia with dilatation of the capillaries and
venules of the supercial plexus [7].
Clinical Manifestations
Infantile seborrheic dermatitis usually develops within the rst
month of life [10]. Infants with seborrheic dermatitis often pre-
sent with focal or diffuse, white or yellow, greasy scaling and
crusting of the scalp (Figure 1) [1, 2]. The lesion may become so
thickened that it forms a cap, meriting its description as cradle cap
[1]. Cradle cap is usually the initial and at times the only manifes-
tation of infantile seborrheic dermatitis [10]. Not uncommonly,
erythematous or salmon-colored sharply demarcated patches with
yellow-white scales may involve the face, external ear, postauricu-
lar folds, trunk, and intertriginous and exural areas of the body
[1]. In the diaper area, infantile seborrheic dermatitis presents as
a sharply demarcated, erythematous, greasy, scaly eruption with
a tendency to coalesce, resulting in the formation of a large con-
uent lesion; it may be mistaken for candidal dermatitis [1]. In
infantile seborrheic dermatitis, oozing, weeping and pruritus are
characteristically absent [11].
In adolescence and beyond, seborrheic dermatitis usually presents
as greasy scaling of the scalp (dandruff). It may also present as
ill-dened erythematous patches with yellow-white, greasy scales
on the nasolabial folds, eyelids, eyebrows, glabella (Figure 2), pos-
tauricular area, anterior chest, and less commonly the upper back
[11, 12]. In contrast to infantile seborrheic dermatitis, pruritus is
common in adolescent seborrheic dermatitis, especially with scalp
involvement [6]. Involvement of the eyelids may lead to blephari-
tis with erythematous eyelids and potential destruction of eye-
lid follicles [7, 8]. The upper chest and back are less commonly
affected [12]. Generalized seborrheic dermatitis is uncommon
which, if present, should lead to the suspicion of an underlying
immunodeciency disorder.
The diagnosis is mainly clinical, based on the characteristic clinical
morphology of scaling and erythema in typical sebum-rich areas.
If necessary, the diagnosis can be aided by dermoscopy which
shows atypical red vessels, arborizing vessels, and structureless
red areas [13]. If tinea capitis is suspected, a potassium hydrox-
ide wet-mount examination of scalp scrapings may help in the
diagnosis. Referral to a dermatologist should be considered if the
diagnosis is in doubt.
Differential Diagnosis
Seborrheic dermatitis should be differentiated from atopic der-
matitis, irritant diaper dermatitis, tinea capitis, psoriasis, rosacea,
Langerhans cell histiocytosis X, and immunodeciency [11]. In-
fantile seborrheic dermatitis is distinguished from atopic derma-
titis by its earlier age of onset, involvement of the scalp, diaper
area, and exural rather than extensor surfaces, well-dened le-
sions with dry ne scaling, absence of oozing or weeping, and
absence of pruritus [10].
Typically, irritant contact dermatitis presents as conuent erythe-
ma and maceration on the convex skin surfaces in contact with
the diaper. The skin has a shiny, glazed appearance. In contrast to
infantile seborrheic dermatitis, the intertriginous folds are usually
Tinea capitis typically presents as ne scaling with patches of cir-
cular alopecia; diffuse or patchy, ne, white, adherent scaling of
the scalp resembling generalized dandruff; or patches of well-de-
marcated areas of alopecia with ne scales, studded with broken-
off, swollen hair stubs, resulting in a “black dot” appearance.
In infants and young children, psoriasis often present as sharply
demarcated erythematous plaques in the diaper and intertriginous
areas. The classic silvery scales are usually absent. Compared to
infantile seborrheic dermatitis, the response to topical corticoster-
oid is much slower, and there is no response to topical antifungals.
Rosacea is characterized by telangiectasia, persistent erythema of
the central face, small, dome-shaped erythematous papules, and/
or tiny pustules on the central aspects of the face. The perioral
and periocular areas are typically spared. Facial ushing, dryness,
scaling, edema, or burning/stinging (“sensitive skin”) sensation
may be present.
Figure 1. Infantile seborrheic dermatitis presenting as yellowish adherent scales and crusting of the scalp.
Figure 2. A 16-year-old boy with seborrheic dermatitis presenting as white scales on the eyebrows and glabella.
Alexander K. C. Leung, Barankin B (2015) Seborrheic Dermatitis. Int J Pediat Health Care Adv. 2(1), 7-9. 9
Langerhans cell histiocytosis X is a multisystem disease that can
be distinguished by the presence of 1 to 3 mm discrete yellowish
to red-brown crusted papules, purpuric lesions, lymphadenopa-
thy, and hepatosplenomegaly. The cutaneous lesions are resistant
to topical corticosteroid [10].
Various immunodeciency states may present with an intractable
seborrhea-like dermatitis. Immunodeciency should be suspected
if there are constitutional ndings such as fever, anemia, diarrhea,
and failure to thrive.
Although scalp hair loss is not usually associated with seborrheic
dermatitis, alopecia may result if the scalp involvement is chronic
and severe [14]. Infantile seborrheic dermatitis may be compli-
cated by superimposed infection with Candida species. Postinam-
matory pigmentary changes may occur, particularly in more pig-
mented individuals [1]. Blepharoconjunctivitis may also occur [3].
In adolescence, the condition can be socially embarrassing and
may have a substantial adverse effect on the quality of life [3, 8].
Infantile seborrheic dermatitis is usually self-limiting, resolving
within several weeks to several months [11]. The majority of cases
clear by 12 months of age [11, 12]. In adolescent and adult sebor-
rheic dermatitis, the disease runs a chronic course with relapses
and remissions [12].
Treatment should be individualized, taking into consideration the
age of the patient, location of the lesion, response to previous
treatment, preference of the patient, and adverse effect of the
medication. Scalp lesions in infantile seborrheic dermatitis usu-
ally respond to more regular shampooing alone or in combination
with the non-prescription mild shampoos specically labelled for
seborrheic dermatitis. For infantile scalp seborrheic dermatitis that
does not respond to the above measures, for seborrheic dermati-
tis lesions elsewhere, and for adolescent or adult seborrheic der-
matitis, the use of topical antifungals (ketoconazole, ciclopirox),
calcineurin inhibitors (tacrolimus and pimecrolimus), and low to
mid potency corticosteroids should be considered, alone or in
combination [2, 15-19]. Topical antifungal agents (ketoconazole,
ciclopirox, sertaconazole) which are available in different formu-
lations such as creams and shampoos are the mainstay of treat-
ment [2, 5, 6]. Shampoos with different active ingredients (e.g.
zinc pyrithione, ketoconazole, selenium sulphide, tar, salicylic
acid) have been used with success [20, 21]. In this regard, zinc
pyrithione-based shampoos are effective, affordable, and have ex-
cellent cosmetic and hair conditioning effects; all of which will
encourage long-term compliance. More frequent shampooing is
often helpful [21].
Oral antifungals (itraconazole, ketoconazole, terbinane, ucona-
zole) or isotretinoin are rarely indicated but may be considered in
selected cases of extensive and severe lesions resistant to topical
treatment [8, 22].
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tralas J Dermatol doi: 10.1111/ajd.12289.
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The authors present the case of a 25-day-old newborn with a well-defined erythematous patch in the right axilla. It was partly covered with foul-smelling exudate and no satellite lesions were present. No other family members were affected and the child was otherwise well. After only 3 days of empiric treatment with local and systemic antibiotics the eruption had already started improving, and after 1 week a complete resolution was obtained.
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Background: Seborrhoeic dermatitis is a chronic inflammatory skin condition that is distributed worldwide. It commonly affects the scalp, face and flexures of the body. Treatment options include antifungal drugs, steroids, calcineurin inhibitors, keratolytic agents and phototherapy. Objectives: To assess the effects of antifungal agents for seborrhoeic dermatitis of the face and scalp in adolescents and adults.A secondary objective is to assess whether the same interventions are effective in the management of seborrhoeic dermatitis in patients with HIV/AIDS. Search methods: We searched the following databases up to December 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 11), MEDLINE (from 1946), EMBASE (from 1974) and Latin American Caribbean Health Sciences Literature (LILACS) (from 1982). We also searched trials registries and checked the bibliographies of published studies for further trials. Selection criteria: Randomised controlled trials of topical antifungals used for treatment of seborrhoeic dermatitis in adolescents and adults, with primary outcome measures of complete clearance of symptoms and improved quality of life. Data collection and analysis: Review author pairs independently assessed eligibility for inclusion, extracted study data and assessed risk of bias of included studies. We performed fixed-effect meta-analysis for studies with low statistical heterogeneity and used a random-effects model when heterogeneity was high. Main results: We included 51 studies with 9052 participants. Of these, 45 trials assessed treatment outcomes at five weeks or less after commencement of treatment, and six trials assessed outcomes over a longer time frame. We believe that 24 trials had some form of conflict of interest, such as funding by pharmaceutical companies.Among the included studies were 12 ketoconazole trials (N = 3253), 11 ciclopirox trials (N = 3029), two lithium trials (N = 141), two bifonazole trials (N = 136) and one clotrimazole trial (N = 126) that compared the effectiveness of these treatments versus placebo or vehicle. Nine ketoconazole trials (N = 632) and one miconazole trial (N = 47) compared these treatments versus steroids. Fourteen studies (N = 1541) compared one antifungal versus another or compared different doses or schedules of administration of the same agent versus one another. KetoconazoleTopical ketoconazole 2% treatment showed a 31% lower risk of failed clearance of rashes compared with placebo (risk ratio (RR) 0.69, 95% confidence interval (CI) 0.59 to 0.81, eight studies, low-quality evidence) at four weeks of follow-up, but the effect on side effects was uncertain because evidence was of very low quality (RR 0.97, 95% CI 0.58 to 1.64, six studies); heterogeneity between studies was substantial (I² = 74%). The median proportion of those who did not have clearance in the placebo groups was 69%.Ketoconazole treatment resulted in a remission rate similar to that of steroids (RR 1.17, 95% CI 0.95 to 1.44, six studies, low-quality evidence), but occurrence of side effects was 44% lower in the ketoconazole group than in the steroid group (RR 0.56, 95% CI 0.32 to 0.96, eight studies, moderate-quality evidence).Ketoconozale yielded a similar remission failure rate as ciclopirox (RR 1.09, 95% CI 0.95 to 1.26, three studies, low-quality evidence). Most comparisons between ketoconazole and other antifungals were based on single studies that showed comparability of treatment effects. CiclopiroxCiclopirox 1% led to a lower failed remission rate than placebo at four weeks of follow-up (RR 0.79, 95% CI 0.67 to 0.94, eight studies, moderate-quality evidence) with similar rates of side effects (RR 0.9, 95% CI 0.72 to 1.11, four studies, moderate-quality evidence). Other antifungalsClotrimazole and miconazole efficacies were comparable with those of steroids on short-term assessment in single studies.Treatment effects on individual symptoms were less clear and were inconsistent, possibly because of difficulties encountered in measuring these symptoms.Evidence was insufficient to conclude that dose or mode of delivery influenced treatment outcome. Only one study reported on treatment compliance. No study assessed quality of life. One study assessed the maximum rash-free period but provided insufficient data for analysis. One small study in patients with HIV compared the effect of lithium versus placebo on seborrhoeic dermatitis of the face, but treatment outcomes were similar. Authors' conclusions: Ketoconazole and ciclopirox are more effective than placebo, but limited evidence suggests that either of these agents is more effective than any other agent within the same class. Very few studies have assessed symptom clearance for longer periods than four weeks. Ketoconazole produced findings similar to those of steroids, but side effects were fewer. Treatment effect on overall quality of life remains unknown. Better outcome measures, studies of better quality and better reporting are all needed to improve the evidence base for antifungals for seborrhoeic dermatitis.
Full-text available
Background: Psoriasis and seborrheic dermatitis are both chronic erythemato-squamous dermatoses that can involve the scalp. It may be difficult to differentiate these two diseases when there is isolated scalp involvement. Recently, trichoscopy is commonly used to differentiate noncicatricial alopecias including psoriasis and seborrheic dermatitis that can lead to telogen effluvium (TE). Objectives: The objective of this study is to evaluate the trichoscopic figures that may help to differentiate scalp psoriasis and seborrheic dermatitis. Materials and methods: Thirty one with scalp psoriasis and 112 patients with seborrheic dermatitis were enrolled. Trichoscopic examinations were performed using a videodermatoscope (MoleMax 3(®)). Trichoscopic findings of scalp psoriasis and seborrheic dermatitis were compared with each other, with 100 healthy individuals and with other noncicatricial alopecias including female androgenetic alopecia (FAGA) (n: 138), male androgenetic alopecia (n: 63), FAGA of male pattern (FAGA.M) (n: 5), alopecia areata (39), TE (n: 22) and trichotillomania (n: 4). Results: Atypical red vessels, red dots and globules (RDG), signet ring vessels (SRV), structureless red areas and hidden hairs (HH) were statistically more common in psoriasis while twisted red loops and comma vessels (CV) in seborrheic dermatitis. RDG were considered as the characteristic videodermatoscopic figure for psoriasis and arborizing red lines and CV for seborrheic dermatitis. In comparison with previous reports, our study yielded two new trichoscopic structures supporting the diagnosis of psoriasis; HH and SRV. Besides, according to our study, CV were described for the first time in seborrheic dermatitis and considered to be specific for seborrheic dermatitis. Conclusion: This study confirmed that trichoscopy might be useful in differentiating scalp psoriasis and seborrheic dermatitis from each other and from other noncicatricial alopecia with three trichoscopic structures as HH, SRV and CV.
In the most important books of pediatric denqatology of the last 50 years the definition od seborrheic dermatitis (SD) is not homogeneous. The description of SD does not match in many cases with the relevant illustrations. The criteria of differential. diagnosis between SD and atopic dermatitis are not precise. Several patients with evident infantile psoriasis were used as example of SD.
Seborrheic dermatitis is a common skin condition in infants, adolescents, and adults. The characteristic symptoms-scaling, erythema, and itching-occur most often on the scalp, face, chest, back, axilla, and groin. Seborrheic dermatitis is a clinical diagnosis based on the location and appearance of the lesions. The skin changes are thought to result from an inflammatory response to a common skin organism, Malassezia yeast. Treatment with antifungal agents such as topical ketoconazole is the mainstay of therapy for seborrheic dermatitis of the face and body. Because of possible adverse effects, anti-inflammatory agents such as topical corticosteroids and calcineurin inhibitors should be used only for short durations. Several over-the-counter shampoos are available for treatment of seborrheic dermatitis of the scalp, and patients should be directed to initiate therapy with one of these agents. Antifungal shampoos (long-term) and topical corticosteroids (short-term) can be used as second-line agents for treatment of scalp seborrheic dermatitis.
An association between adult scalp seborrhoeic dermatitis and cicatricial hair loss has not previously been convincingly established. This study seeks to demonstrate a unique relationship between a clinically identifiable chronic scalp dermatitis-folliculitis with the characteristic histological features of low-grade inflammatory fibrosing alopecia, resulting in a distinctive progressive cicatricial alopecia which we believe is prevalent and hitherto unrecognised, and befits the description of seborrhoeic folliculitis. The clinical, epidemiological and histopathological features of seborrhoeic folliculitis are demonstrated to establish its unique status among the disorders of adult diffuse cicatricial alopecia. © 2015 The Australasian College of Dermatologists.
Atopic dermatitis and seborrheic dermatitis are multifactorial dermatitides that are known collectively as endogenous dermatitis. Both conditions can affect the face, but they have clinical, epidemiological, and physiopathological peculiarities that distinguish them from each other. These two diseases are very common all around the world. Atopic dermatitis is associated with xerosis and increased susceptibility to irritants and proteins; patients with this condition have a tendency to develop asthma, allergic rhinitis, and systemic manifestations that are mediated by immunoglobulin E. Seborrheic dermatitis is a moderate chronic dermatitis that is restricted to regions with a high production of sebum and areas that have cutaneous folds. There are many studies about pathophysiology related to the immunology and genetics of atopic dermatitis, but little is known about the genetic and immunological markers of seborrheic dermatitis.
The treatment of seborrheic dermatitis (SD) includes topical antifungal agents to eradicate Malassezia spp. corticosteroids to treat the inflammatory component of the disease, and keratolytics to remove scale and crust. The aim of this study was to compare the efficiency of sertaconazole 2% cream and tacrolimus 0.03% cream in the treatment of seborrheic dermatitis. In this clinical trial study, sixty patients suffering from SD were studied. Thirty patients received local sertaconazole 2% cream with a recommendation to use the cream twice a day for 4 weeks. In the control group, thirty patients received tacrolimus 0.03% cream twice a day for four weeks. At the time of referral, and 2 and 4 weeks after first visit, the patients were examined by a dermatologist to check the improvement of clinical symptoms. The mean ages of the sertaconazole and tacrolimus groups were 30.98 +/- 12.24 and 34.67 +/- 10.82, respectively. The highest level of satisfaction (90%) was observed 28 days after sertaconazole use. Only 83.3% satisfaction was noted in the tacrolimus group. The relationship between patient satisfaction and sertaconazole 2% cream receive in 28th day was significant (P = 0.006). Sertaconazole 2% cream may be an excellent alternative therapeutic modality for treating seborrheic dermatitis.
Seborrheic dermatitis (SD) is a common skin condition seen frequently in clinical practice. The use of varying terms such as sebopsoriasis, seborrheic dermatitis, seborrheic eczema, dandruff, and pityriasis capitis reflects the complex nature of this condition. Despite its frequency, much controversy remains regarding the pathogenesis of SD. This controversy extends to its classification in the spectrum of cutaneous diseases, having being classified as a form of dermatitis, a fungal disease, or an inflammatory disease, closely related with psoriasis. Some have postulated that SD is caused by Malassezia yeasts, based on the observation of their presence in affected skin and the therapeutic response to antifungal agents. Others have proposed that Malassezia is incidental to a primary inflammatory dermatosis that resulted in increased cell turnover, scaling, and inflammation in the epidermis, similar to psoriasis. The presence of host susceptibility factors, permitting the transition of M furfur to its pathogenic form, may be associated with immune response and inflammation. Metabolites produced by Malassezia species, including oleic acid, malssezin, and indole-3-carbaldehyde, have been implicated. SD also has been traditionally considered to be a form of dermatitis based on the presence of Malassezia in healthy skin, the absence the pathogenic mycelial form of Malassezia yeasts in SD, and its chronic course. As a result, proposed treatments vary, ranging from topical corticosteroids to topical antifungals and antimicrobial peptides.
Seborrheic dermatitis (SD) is normally treated with topical corticosteroids and antifungals. Oral therapies can be prescribed in severe or unresponsive cases. This review aims to assess the quantity and quality of published reports on oral therapies for SD. MEDLINE and Embase databases and the reference listings of publications were searched for any publication using oral treatment for SD. The quality of the included publications was assessed using a modified 27 item checklist by Downs and Black. Twenty-one publications (randomized controlled trials, open trials and case reports) covering eight oral therapies (itraconazole, terbinafine, fluconazole, ketoconazole, pramiconazole, prednisone, isotretinoin and homeopathic mineral therapy) were identified. Most of the publications investigated oral antifungals and the quality of the evidence was generally low. The clinical efficacy outcome reported varied considerably between the studies, preventing statistical analysis and direct comparison between treatments. However, ketoconazole therapy was associated with more relapses compared with other treatments. Itraconazole dosing regimen for SD was generally 200 mg/day for the first week of the month followed by 200 mg/day for the first 2 days for 2-11 months. Terbinafine was prescribed at 250 mg/day either as a continuous (4-6 weeks) or as an intermittent regimen (12 days per month) for 3 months. Fluconazole has administered daily (50 mg/day for 2 weeks) or weekly (200-300 mg) for 2-4 weeks. Ketoconazole dosing regimen was 200 mg daily for 4 weeks. Finally, a single 200 mg dose of pramiconazole was administered to patients. This review also highlights key areas for consideration when designing future studies.
Objectives: Dandruff is a chronic, relapsing scalp condition that negatively impacts the quality of life of sufferers. Regular use of anti-fungal shampoos represents a proven therapeutic strategy to improve the most common symptoms of flakes and itch. Two recent approaches for enhancing the efficacy of anti-fungal shampoos are maximizing bio-availability of the active material or the addition of a second active material. Our aim is to compare the therapeutic efficacy of these two approaches - maximization of bio-availability of the zinc pyrithione (ZPT) active material or the combination of ZPT with a secondary active material. Methods: The anti-fungal potency of shampoos representing each of these approaches was evaluated in vitro using a standard microbiology method. Spatial delivery of ZPT particles in the follicular infundibulum was assessed in vivo using a novel confocal microscopy methodology. Clinical efficacy was assessed in a randomized, double-blind trial involving 620 male and female subjects using scalp flaking and epidermal histamine level as endpoints. Results: The shampoo formula with maximized ZPT bio-availability known as the Potentiated ZPT formula exhibited greater anti-fungal potency than the Dual Active shampoo containing both ZPT and climbazole. The Potentiated ZPT formula also delivered more ZPT to the lower infundibulum than the Dual Active shampoo. A 4-week treatment with the Potentiated ZPT formula resulted in superior clinical efficacy compared with the Dual Active product at all 4 weekly time points for both flaking and epidermal histamine endpoints. Conclusion: These results highlight the critical role that the shampoo vehicle plays in realizing full potency of active materials. By optimizing the delivery vehicle, the enhanced anti-fungal potency and the maximized spatial delivery of active materials result in greater symptomatic improvement than a product with two active materials. The therapeutic efficacy of a product based on a complex delivery vehicle such as a shampoo must be considered from a full-product perspective rather than just the active system as the non-active components of the composition will often play a significant role in the overall product pharmacology and resultant efficacy.