History
A 29-year-old man attends your clinic with a 4-year history of a recurrent and itchy facial eruption that he feels is unsightly. He notices the eruption is worse in the winter and tends to improve over the summer. He is currently studying for business exams and feels the associated stress has triggered the current flare. He avoids soaps, which make his face sore, and recently has reduced his alcohol intake in an effort to improve his eruption. He is otherwise well and on no medication.
Examination
A full examination is unremarkable except for the skin of his face, neck, central chest and scalp. There are poorly defined erythematous patches with overlying adherent greasy scale affecting his naso-labial folds and extending onto his cheeks (Fig. 4.1). His eyebrows, scalp, nape of his neck and central chest are similarly affected.
Questions
• What is this eruption?
• What age groups are affected?
• How would you manage this patient?
Medicine
This eruption is seborrhoeic dermatitis. It is more common among men and typically affects the sebum-rich areas of the face, scalp and chest. The pathophysiology of sebor-rhoeic dermatitis is incompletely understood, however. It is linked with Malassezia yeast, complement activation and abnormalities of T-cell immunity. It may worsen in individu- als infected with HIV or affected by Parkinson’s disease. The condition usually begins around puberty with a peak of incidence between 25 and 40 years of age. An infantile form of seborrhoeic dermatitis may manifest as cradle cap (Fig. 4.2), facial greasy scaly dermatitis, napkin dermatitis and, rarely, as an erythroderma. In predisposed individuals seborrhoeic dermatitis usually recurs. Treatment is aimed, therefore, at reducing morbidity and preventing flares. Treatment aims are two-fold: reducing the yeast burden as a secondary preventative measure, and switching off the resultant secondary dermatitis when it occurs. Although topical corticosteroids may improve appearances of the dermatitis in the short term, they are thought to hasten recur-rences and may foster dependence due to a ‘rebound effect’ and are usually discouraged. The use of a ketoconazole shampoo, with frequent washing and prolonged lathering often improves associated dandruff and may improve the facial involvement by depletion of Malassezia. Use of ketoconazole shampoo as a face wash can be irritating, but if toler-ated may improve erythema and scaling. Ketoconazole or miconazole cream, calcineurin inhibitors in combination with antiseptic emollient washes are recommended. For severe or refractory seborrhoeic dermatitis systemic itraconazole as a short course or ‘pulsed’ (one week per month) is highly effective at reducing the yeast burden.
KEY POINTS
• Seborrhoeic dermatitis is characterized by poorly defined erythematous patches with overlying greasy, yellowish-brown scale localized to the sebum-rich areas.
• It occurs most commonly among men from adolescence to middle age. Infantile seborrhoeic eczema can also occur.
• HIV infection and Parkinson’s disease are both associated with refractory seborrhoeic dermatitis.
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