Changes

November 2024 — minor update. Revised advice on the potency of topical steroids to use when treating seborrhoeic dermatitis. 

Update

Goals

To support primary healthcare professionals to:

• Make a diagnosis of seborrhoeic dermatitis.
• Prescribe appropriate topical medication.
• Refer to secondary care for further assessment and management where appropriate.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

NICE quality standards

What is it?

• Seborrhoeic dermatitis is a common chronic inflammatory skin condition which occurs in areas rich in sebaceous glands (such as the scalp, nasolabial folds, upper lip, ears, eyelids, eyebrows, chest, flexures and skin folds).
  • It typically presents as erythematous patches with greasy-looking yellowish scales – distribution is usually symmetrical.
  • Dandruff, which is restricted to the scalp, is considered to be a mild non-inflammatory form of seborrhoeic dermatitis. 
• Seborrhoeic dermatitis in infants is most common in the first 3 months of life and mainly affects the scalp (also known as 'cradle cap').
  • The face, neck, skin flexures, and nappy area can also be involved.

[Borda, 2015; Clark, 2015; Adalsteinsson, 2020; Buckley, 2021a; Buckley, 2021b; BMJ Best Practice, 2022; Dall'Oglio, 2022]

What causes it?

• The exact cause of seborrhoeic dermatitis is not fully understood — many factors, including the presence of Malassezia yeasts and elements of host immune response, have been associated with its development. 
  • Malassezia is a normal component of the skin flora, but in people with seborrhoeic dermatitis, it causes the release of lipases which results in free fatty acid formation and the start of an inflammatory process. However, exogenous factors (such as other microbiota, stress, weather conditions, and medication) are also important in the pathophysiological process. 
  • A correlation between levels of yeast carriage and symptoms in people with and without seborrhoeic dermatitis has not been identified. 
  • Treatment with antifungals decreases the number of Malassezia yeasts and leads to clinical improvement — recolonization precedes relapse.
• Seborrhoeic dermatitis typically occurs in healthy people but can also be associated with certain underlying conditions, including: 
  • Immunodeficiency (for example, HIV). 
  • Neurological disorders (for example, Parkinson’s disease and stroke). 
  • Some genetic disorders (for example, Down’s syndrome). 

[Goldenberg, 2013; Borda, 2015; Clark, 2015; Hald, 2015; Adalsteinsson, 2020; BMJ Best Practice, 2022]

How common is it?

• Seborrhoeic dermatitis is a common skin disorder — estimated prevalence varies from 1-5% in the general adult population.
  • It is more common in men than in women.
    • A comparative cross‐sectional study (n= 5498; 788 with seborrhoeic dermatitis) reporting on a prospective population‐based cohort of middle‐aged and elderly people found that men were twice as likely to have seborrhoeic dermatitis as women [adjusted OR 2·09, 95% CI 1·77–2·47]) [Sanders, 2018].
• Incidence is highest in infants younger than 3 months of age (up to 70% of children), during adolescence and in adults aged 30–60 years.
  • Incidence of seborrhoeic dermatitis affecting the scalp (‘cradle cap’), the face, and nappy area in infants up to three months of age is reported to be up to 42% [Borda, 2015].
• The prevalence of seborrhoeic dermatitis is higher in people with:
  • Immunosuppression — reported prevalence varies from 30-83% in immunocompromised people (for example, HIV infection).  
  • Chronic neurological conditions such as Parkinson's disease.

[Borda, 2015; Clark, 2015; Hald, 2015; Adalsteinsson, 2020; BMJ Best Practice, 2022]

What are the complications?

• Complications include:
  • Secondary infection (for example, impetigo or otitis externa) is the most common complication. 
  • Lowered self-esteem or psychological distress due to chronic visible disease.
  • Erythroderma — rarely; generalized seborrhoeic dermatitis can result in erythroderma.

[WHO, 2014; Borda, 2015; BMJ Best Practice, 2022]

What is the prognosis?

• Adults
  • In adults, seborrhoeic dermatitis is a chronic condition — symptoms fluctuate over time, and it responds well to treatment, but it may relapse and remit over many years.
• Infants
  • Infantile seborrhoeic dermatitis is usually self-limiting, and lesions normally resolve at around 8-12 months. 

[Borda, 2015; Clark, 2015; Hald, 2015; Adalsteinsson, 2020; Buckley, 2021a; BMJ Best Practice, 2022] 

What are the clinical features of seborrhoeic dermatitis?

In adolescents and adults:

• Seborrhoeic dermatitis is characterised by:
  • Well-defined erythematous plaques with superficial greasy-looking white or yellow scales.
    • In people with darker skin, seborrhoeic dermatitis may present with hypopigmented scaly patches, and erythema may be difficult to detect. 
  • Lesions are usually distributed symmetrically in regions rich in sebaceous glands, but signs may be more widespread in people who are immunocompromised.
    • In people with HIV, seborrhoeic dermatitis may be quite extensive, spreading beyond commonly affected areas.
  • Pruritus is often present, particularly in more inflammatory forms and especially when the scalp is involved. Occasionally, this can be severe.
• The most commonly affected areas are the:
  • Face (87.7%) — in particular, the nasolabial folds, glabellar area, eyebrows, and behind the ears.
    • There may be yellowish scaling between eyelashes, and blepharitis may develop.  
    • There may be crusting, oozing and fissures behind the ears, which may spread to the external ear canal.
  • Scalp (70.3%) — lesions can range from mild desquamation (dandruff) to honey-coloured crusts that adhere to skin and hair. Itch is common and can be very severe. 
  • Upper chest and back (26.8%) — different forms of seborrhoeic dermatitis may be apparent:
    • Petaloid type — petal-shaped lesions typically develop on the upper chest.
    • Pityriasiform type (less common) — widespread oval-shaped scaly macules and patches distributed similarly to extensive pityriasis rosea.
  • Legs (2.3%) and arms (1.3%).
• Other areas include flexures and skin folds (in particular axillae, genital or inguinal area, breast fold, and umbilicus). 
• Adolescents of Hispanic, Asian, and African origin may present similarly to adults, with hypopigmented scaly plaques on the eyebrows and perinasal region.
• Severity varies markedly from person to person — some people may only experience mild patches, whereas others have more widespread lesions or severe onset.
  • The possibility of HIV infection should be considered in people who present with severe or widespread seborrhoeic dermatitis.
• Images of seborrhoeic dermatitis can be found on www.dermnetnz.org.

In infants:

• Infantile seborrhoeic dermatitis occurs mostly in the first 3 months of life and usually resolves by 8–12 months.
• Characteristically there is extensive coverage of the scalp (cradle cap), but the face, ears, neck, skin flexures, and nappy area may also be affected. Features at presentation include: 
  • Scalp — non-inflammatory eruption of thick white, red, or yellow greasy scales mainly affecting the vertex and frontal areas. 
  • Face — erythematous, flaky, salmon-coloured plaques on the forehead, eyebrows, eyelids, nasolabial folds, or retro-auricular areas.
  • Body folds — lesions have moist, shiny, non-scaly aspects that tend to coalesce on the neck, axillae, or inguinal area.
  • Trunk — sharply limited plaques of erythema and scaling over the lower abdomen.
• A generalized rash, similar to atopic eczema, may develop with widespread erythematous scaly lesions, but there is usually little or no itch and infants rarely scratch.  
  • An explosive, often generalized, onset of SD may be a marker for HIV infection. If extensive or severe seborrhoeic dermatitis is present in a child, underlying causes, including immunosuppression, should be considered. 
• In children of colour, the standard cradle cap appearance is absent — children often present with erythema, flaking, and hypopigmented of affected areas and overlying atopic dermatitis, which accentuates hypopigmentation. 
• Images of seborrhoeic dermatitis can be found on www.dermnetnz.org.

How should I assess a person with suspected seborrhoeic dermatitis?

Take a history asking about:

• Onset, evolution and distribution of clinical features such as erythema, scaling and pruritus.
• Aggravating factors (for example, environmental, emotional, infectious) and relieving factors.
• Associated features such as failure to thrive in an infant and impaired immunity are suggestive of an underlying condition, especially in people who present with sudden onset of severe or extensive seborrhoeic dermatitis.
• Past medical history, including conditions which may predispose to seborrhoeic dermatitis, such as HIV and Parkinson’s disease.
• Current medication — some drugs are associated with seborrhoeic dermatitis, including chlorpromazine, cimetidine, gold, interferon‐alpha, and methyldopa. 

Examine the person looking for:

• Typical features of seborrhoeic dermatitis such as erythematous scaly patches in areas rich in sebaceous glands — severity can vary from mild flaking to widespread, oily, dense scaling or crusting. 

Consider the need for further investigations:

• Diagnosis is usually clinical — investigations (such as blood tests, skin scrapings, or skin biopsy) may be appropriate if an underlying cause (such as HIV) or alternative diagnosis (such as tinea or lupus) is suspected. 

What else might it be?

• Actinic keratosis — this may appear as an erythematous papule with scales that are more adherent than in seborrhoeic dermatitis. 
• Atopic dermatitis — family history of atopy, frequently involves scalp, cheeks and extensor areas. Flexure involvement is more frequent in older ages.
  • For more information, see the CKS topic on Eczema – atopic 
• Candidiasis — usually confined to mucous membranes and intertriginous areas. 
  
  • For more information, see the CKS topic on Candida - skin.
• Contact dermatitis — there is dermatitis at the site of contact which is often sharply demarcated.
  • For more information, see the CKS topic on Dermatitis - contact.
• Erythroderma — extensive widespread erythema. May be due to a flare of seborrhoeic dermatitis, a pre-existing skin condition, lymphoma or drug eruption.  
• HIV infection — seborrhoeic dermatitis/exanthema is an HIV indicator condition. For more information, see the CKS topic on HIV HIV infection and AIDS.
• Impetigo — characteristic golden crusts, typically on the face. 
  • For more information, see the CKS topic on Impetigo. 
• Lichen simplex — eczematous eruption caused by habitual scratching of a single localized area. More common in adults. 
• Pityriasis rosea — there is often a herald patch and 'Christmas tree' distribution of salmon pink papules over the trunk and proximal extremities. 
  • For more information, see the CKS topic on Pityriasis rosea.
• Pityriasis versicolor — a slightly scaley rash that affects the trunk and upper arms and is most common in the summer months. Usually presents with hypopigmented or hyperpigmented macular rash of varying colour (brown, pink, or white) with fine scales. 
  • For more information, see the CKS topic on Pityriasis versicolor.
• Psoriasis — usually more red and scaly with sharply demarcated round-to-oval plaques. Plaques tend to be thicker with silvery-white scales. Other signs include nail changes (for example, pitting).  
  • For more information, see the CKS topic on Psoriasis.
• Rosacea — erythematous, oedematous eruptions of papules and pustules on the forehead, cheeks, nose, and eyes.
  • For more information, see the CKS topic on Rosacea.
• Secondary syphilis — copper-coloured scaly plaques on palms and soles accompanied by an influenza-like syndrome and generalized adenopathy. 
  • For more information, see the CKS topic on Syphilis. 
• Systemic lupus erythematosus (SLE) — sub-acute SLE may have similar features to seborrhoeic dermatitis; plaques are less scaly. In the acute stage, a butterfly rash on the face spares the nose bridge or nasolabial folds. Photosensitivity is common.
• Tinea capitis (fungal infection of the scalp) — presents with scalp scaling. May not be inflammatory or erythematous. Alopecia may be present.
  • For more information, see the CKS topics on Fungal skin infection – body and groin and Fungal skin infection – scalp.
• Some drugs and nutritional deficiencies may induce a seborrhoeic dermatitis-like rash:
  • Drugs include gold, haloperidol, chlorpromazine, cimetidine, interferon-alpha, methyldopa, and psoralens.
  • Nutritional deficiencies include pyridoxine, zinc, niacin, and riboflavin. 

In infants, differential diagnoses also include:

• Histiocytosis — rare; brown to purplish papules prone to coalesce on the scalp, retro-auricular areas, axillae and inguinal folds. It can affect the scalp, trunk, and nappy area.
• Leiner's disease — associated with immunodeficiency. Erythroderma is common, widespread seborrhoeic dermatitis, recurrent infections, concurrent diarrhoea, and failure to thrive.

Scenario: Seborrhoeic dermatitis - infants

From birth to 12 months.

Scenario: Seborrhoeic dermatitis - scalp and beard

From age 12 months onwards.

Scenario: Seborrhoeic dermatitis - face and body

From age 12 months onwards.

Topical imidazoles

Ketoconazole cream and shampoo 

• Adverse effects
  • Skin reactions, folliculitis and hair changes.
• Pregnancy and breastfeeding
  • The manufacturer of ketoconazole shampoo advises that it is not contraindicated in women who are pregnant or breastfeeding but should be used with caution, and the manufacturer of ketoconazole cream advises that there are no known risks associated with use in pregnancy or lactation.

Clotrimazole 

• Adverse effects
  • Allergic reactions.
  • Local skin reactions, including pruritus, rash, blisters and erythema.
• Pregnancy and breastfeeding
  • There is low systemic absorption after topical application, and it is not known to be harmful in women who are pregnant or breastfeeding. 

Miconazole [MHRA, 2016] 

• Adverse effects
  • Skin reactions such as pruritus, irritation, inflammation, discomfort and hypopigmentation.
• Drug Interactions
  • There is limited systemic absorption after topical application, however, systemic administration inhibits CYP3A4, and while clinically relevant drug interactions are rare after topical application, the manufacturers advise caution in people taking oral anticoagulants such as warfarin. 
• Pregnancy and breastfeeding
  • Only small amounts of miconazole are absorbed following topical administration, but the manufacturer advises caution in women who are pregnant or breastfeeding.

[EMC, 2020; BNF, 2023; EMC, 2021; EMC, 2022; EMC, 2023a] 

Topical corticosteroids

• For detailed information on prescribing corticosteroids see the CKS topic on Corticosteroids - topical (skin), nose, and eyes.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of seborrhoeic dermatitis.

Search dates

January 2019 - September 2023

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 29th January 2019). The strategy was adapted for The Cochrane Library databases. 

S4    S1 OR S2 OR S3 
S3    AB cradle cap OR TI cradle cap 
S2    AB ( ((seborrhoeic or seborrheic) N2 (dermati* or eczema*)) ) OR TI ( ((seborrhoeic or seborrheic) N2 (dermati* or eczema*)) ) 
S1    (MH "Dermatitis, Seborrheic") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.