Elsevier

Clinics in Dermatology

Volume 31, Issue 4, July–August 2013, Pages 343-351
Clinics in Dermatology

Seborrheic dermatitis: Etiology, risk factors, and treatments:: Facts and controversies

https://doi.org/10.1016/j.clindermatol.2013.01.001Get rights and content

Abstract

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.

Introduction

Seborrheic dermatitis (SD) is a common, chronic, relapsing skin disease affecting the seborrheic areas of the body including the scalp, face (nasolabial folds, ears, and eyebrows), and upper part of the trunk (chest/presternal region). Some patients with SD also may present with inflamed erythematous folliculitis (possibly caused by Malassezia) and blepharitis.

Overall, SD affects 1% to 3% of immunocompetent adults, and it is more common in men than in women.1., 2. SD occurs most commonly in infants within the first 3 months of life, in adolescents and young adults, with the incidence increasing again in patients older than 50 years of age.1., 3., 4. A cross-sectional case note study in a Greek teaching hospital between 1995 and 2002, reported 2035 patients diagnosed with SD, giving an overall relative prevalence of 4.05%.5 Comparisons with data from pediatric cross-sectional studies showed that the relative prevalence of SD in Greek outpatient children aged 0 to 15 years (2.5%) was lower than that in Indian6 (11.3%) and Chinese7 (3.2%) children, whereas in adults (4.05%), it was lower than Chinese7 (7%), similar to Iranian,8 and higher than British populations9 (2.35%).

SD is increasingly being recognized to have a substantial negative effect on the patient's quality of life (QoL). In a study of 3000 patients with SD and/or dandruff, patients with dandruff had significantly better QoL than patients with SD or patients with SD plus dandruff (P < 0.001 for both comparisons).10

The use of varying terms such as sebopsoriasis, seborrheic dermatitis, seborrheic eczema, dandruff, and pityriasis capitis reflects the vast clinical spectrum of SD and the controversy regarding its etiology, being considered at times a form of dermatitis, a precursor of psoriasis or a fungal disease.1., 10. Diagnosis remains a clinical one, based on the characteristic clinical morphology of erythema and scaling and the distribution of lesions on the scalp (Figure 1), nasolabial folds, eyebrows, postauricular areas, and the sternum. The distribution of lesions is generally symmetrical. Absence of a standardized definition of SD has been an obstacle to scientific investigation and its differentiation from dandruff.11 Dandruff can be considered a mild form of SD, with scalp scaling and/or mild to marked erythema of the nasolabial fold during times of stress.10., 12. The severity of SD varies. Some patients experience only a mild flaking dandruff, whereas others demonstrate a severe oily, scaling on the scalp, face, and trunk.12

Section snippets

Etiology of seborrheic dermatitis: facts

SD is a multifactorial skin disease that needs endogenous and exogenous predisposing factors for its development. The fact that SD is more common in men and that, except in infants, it begins to develop at puberty, suggests a significant hormonal influence, mainly of androgens.1., 13. The age prevalence of SD coincides with the period of life when sebaceous glands are most active; moreover, SD lesions are located in sebaceous gland-rich body areas. The skin surface lipid composition in males

Seborrheic dermatitis: the Malassezia theory

Louis-Charles Malassez (1842-1909) first proposed the connection between fungi and SD in 1874.38 Lipophilic yeasts of the genus Malassezia (former Pitryrosporum) are commensals of the microbiota found on normal skin of 75% to 98% of healthy adults, and they possess the ability to metabolize fatty compounds in sebum. These yeasts are the cause of pityriasis versicolor and Malassezia folliculitis and appear to be involved in the pathogenesis of common skin disorders, such as SD, psoriasis, and

Treatments

Although SD has no permanent cure, a variety of treatment options are available that can effectively treat this condition. Therapy centers on the control of acute flares and on maintaining remission with long-term therapy. Efficacy, ease of use, safety, and compliance issues need to be considered when selecting a treatment to provide the best clinical outcome. The age of the patient is also an important consideration.

Established treatments include symptomatic therapies such as keratolytics and

Conclusions

SD is a common skin condition seen frequently in clinical practice. Despite its frequency, much controversy remains regarding its pathogenesis. This controversy extends to its classification in the spectrum of cutaneous diseases, having been classified as a form of dermatitis, or a fungal disease, or a disease closely related with psoriasis. As a result, treatments vary, ranging from topical corticosteroids to topical antifungals and AMPs. These scientific questions are yet to be answered.

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      Facial SD is frequently associated with rosacea. The goal of therapy is to clear visible signs of disease and reduce associated symptoms and must be maintained long-term to prevent recurrence.2 Since the underlying mechanism involves, at least in part, Malassezia proliferation and inflammation, common treatments include antifungal and anti-inflammatory therapy.5

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