Comprehensive overview of "seborrheic dermatitis”further evidence showing the effectiveness and safety of pimecrolimus

1. Comprehensive overview of
"seborrheic dermatitis”
further evidence showing the effectiveness and safety of pimecrolimus
Almansouri Daifallah MD

2. Outcomes
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Terminology:
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Origin:
Arabic:
French:
Synonym:
Definition.
Etiology
Risk factors
Epidemiology
Pathophysiology
Dermatopathology
Local Symptoms
Systemic symptoms:
Signs
Investigation, and DDx,
DDx
Complications
Prognosis
Psychological impact
Guidelines
Priscription table of 1st line medication dose
2 commonest and 2 most serious side effects:
Patient education
Progression, severity and response assessment methods

3. Definition
• Seborrhoeic dermatitis (SD) is chronic-recurrent
common skin inflammation affect sebaceousgland-rich areas of skin causes scaling.
• Dandruff(pityriasis sicca): mildest form of
seborrhoeic dermatitis “scaling without
inflammation”.
• Cradle cap “
” : is transient form of
seborrhoeic dermatitis affecting infants.
• SD may be presoriatic stage and may associated
with psoraisis and called “seborrhiasis”

4. Terminology
– Origin:
• Seborrhic: adjective from “sebum” and means that the
disease particularly affects the sebaceous-gland-rich
areas of skin. But not caused by seborrhoea.
• Dermatitis: derma: skin, -itis: inflammation.
– Arabic:
– French: dermatite séborrhéique
– Synonym: Dandruff(pityriasis sicca), cradle cap.

5. Cradle cap
• DDx:
langerhans
cell
histocytosis

6. Etiology
• Unknown
• Possible factors:
– ? Malassezia species
– ? Immune response: decrease some immunity
component.
– Genetic; small role.

7. Risk factors
• HIV; 10X and resistant
• Neural diseases;
Parkinson disease, facial
palsy
• Neuroleptic
medications
• Emotional stress

8. Epidemiology
• %
• Two peaks: infant after 2 wks + 20s -30s.
• M>F

9. Pathophysiology
Genetics:
Immune system
NB. The amount of
malassezia is not
changed.
Malassezia species
•Helper T cells,
phytohemagglutinin and
concanavalin stimulation,
and antibody titers
Malassezia globosa•
Malassezia furfur•
Malassezia restricta•
Malassezia
grow and
secrete lipases
This lipase hydrolyzes sebum TG into > unsaturated fatty acid
(non-uniform) > penetrating the skin cause > epidermal hyperprolifration (causes parakeratosis) and inflammation (causes
spongiosis) >flakes shedding , loss skin barrier function.
RESULT: Inflammation > pruritis. Hyperprolifration> flakes = SD

12. Summery of pathophysiology
• Malassezia ecosystem and interaction with
the epidermis.
• Initiation and propagation of inflammation;
• Disruption of proliferation and differentiation
processes of the epidermis; and
• Physical and functional skin barrier disruption.

13. Dermatopathology
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Spongiosis
focal parakeratosis (partially
nucleated cells)

14. Local symptoms and signs
Symptoms
• Pruritus
• sensation of tightness
“dryness”.
• Hair: alopecia and less
shine.
Aggravated by: winter, dry,
indoor, sweating.
Signs
• Skin: Orange-red
“erythema” OR grey white.
• Scaling macules: white/
greasy/ yellow orange.
• Dryness “sensation of
tightness”.
• Hair: brittle narrow hair.

15. Corona seborrhoica
Where?
confined to areas of
the head and trunk
where sebaceous
glands are most
prominent.
Classification:
area based

16. Classification: Head
• Areas:
– Scalp,
– eyebrows
– eyelashes
(blepharitis)
– beard (follicular
orifices)

17. Classification: face
• Areas:
• forehead (“corona
seborrhoica”),
• nasolabial folds
• eye-brows
• Glabella

18. Classification: Trunk

19. Classification: Body Folds
Areas:
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Axillae,
Groins,
Anogenital area,
Submammary areas,
Umbilicus,
Diaper area
Description: diffuse, exudative,
sharply marinated, brightly
erythematous eruption; erosions
and fissures common.
Tx:
Same as other areas but
Castellani's paint is very
effective

20. Management (nice+aad)
I. Remove crust: salicylic acid, olive oil, coal tar
shampoo.
II. Ketoconazole 2% shampoo
I.
II.
III.
If failed > Selenium sulphide shampoo 2.5% or ciclopirox 1%.
If no compliance > zinc pyrithione shampoo
If symptoms subside > continue: once week for 2 weeks.
III. Severe itching: potent steroid
I.
betamethasone valerate 0.1%,
II.
hydrocortisone butyrate 0.1%
III.
mometasone furoate 0.1%.
Nb. Steroid not applied on bear.
IV. F/U not required unless complicated or resistant

21. Prescription
Medication
Route
dose
salicylic acid
shampo
o
Message for few Once daily
minutes after
wetting hair
One month
Ketoconazol
e 2%
shampoo
shampo
o
left on for five to Twice/week
ten minutes
One month
Pimecrolimu Cream
s 1%
fluocinolone shampo
acetonide
o
0.01%
frequency
duration
Twice daily
≤30 mL
2-4 weeks
safe
Once daily
2-4 weeks
Quick
Zinc + B6
retinoic acid
Spec Indicati
To exclude
deficiency
orally
1mg/ Kg
daily
2 weeks
Very severe

22. Medication SE
Medication
Contraindications
salicylic acid
Sick child or < 2yr
Ketoconazole 2%
shampoo
Safe for pregnant
SE
Management
Irritation/ burning
sensation
dryness
fluocinolone
acetonide 0.01%
hypersensitivity
to peanuts
over-the-counter
conditioner
TC complications
Stop immediately.
Very safe, rarely;
irritation
Subside within 1st
day
Pregnancy; Cat C
Pimecrolimus

23. DDx
Disease
Face
Differentiation
Smear for bacteria
Pitryasis rosea
KOH
Pitryasis varsicolor
Other
Response to Rosacea Tx
Impetigo
Trunk
Rosacea
KOH
Dermatophytosis
KOH
Mild psoriasis vulgaris
Indistinguishable

24. Dandruff
• Dandruff is desquamation without
inflammation.
• Tx: zinc pyrithione shampoo 1 to 2%.

25. SD-like lesions
• B6 or zinc oxide deficiency.

26. Follow Up
• Response assessment:
• Relapse is prevented by once/ week antifungal
shampoo usage.

27. Summary
• Flaking and pruritus are hallmark of SD.

28. References
• http://www.pgbeautygroomingscience.com/r
ole-of-lipid-metabolism-in-seborrheicdermatitis-dandruff.php
• http://www.ncbi.nlm.nih.gov/pubmed?term=
6220754
• http://www.medicaljournals.se/acta/content/
?doi=10.2340/00015555-1382&html=1