Clinical Manual for Management of the HIV-Infected Adult
2006 Edition

Section 6: Disease-Specific Treatment

Seborrheic Dermatitis

Background

Seborrheic dermatitis is one of the most common skin manifestations of HIV disease. It occurs in <5% of the general HIV-uninfected population, but in 34-83% of those with advanced HIV disease. It may flare and subside over time, and tends to worsen after severe illness. Seborrheic dermatitis is characterized by reddish or pink patches of skin, accompanied by greasy flakes or scales. It most commonly occurs in the scalp and on the face, especially at the nasolabial folds, eyebrows, and forehead, but also may develop on the ears, chest, upper back, axillae, or groin. Occasionally, seborrheic dermatitis may be severe and may involve large areas of the body.

The etiology of seborrheic dermatitis is not entirely clear. Malassezia yeast (formerly called Pityrosporum ovale) may play a causative role, as may high sebum levels.

S: Subjective

The patient complains of a new rash, sometimes itchy, or of "dry skin" that will not go away despite the application of topical moisturizers.

O: Objective

Perform a thorough evaluation of the skin with special attention to the scalp, nasolabial folds, ears, eyebrows, eyelashes, central chest, back, axillae, and groin. Seborrheic dermatitis appears as greasy or waxy flakes of skin over red or pink patches of skin. The distribution often is symmetrical.

A: Assessment

The diagnosis of seborrheic dermatitis usually is based on the characteristic appearance. A partial differential diagnosis includes psoriasis and rosacea.

P: Plan

Treatment

• Antiretroviral therapy, if otherwise indicated.
• Topical antifungal medications: various preparations are available; selection can be based on cost and availability. Antifungals may be used in combination with topical corticosteroid therapy (see below). Effective antifungals are not limited to this list.
  • Ketoconazole (Nizoral) 2% cream or shampoo. Studies suggest this is as effective as 1% hydrocortisone cream. Ketoconazole is one of the most widely studied of all topical treatments.
  • Bifonazole ointment, miconazole cream (Monistat), terbinafine (Lamisil) 1% solution, or clotrimazole (Lotrimin) 1% cream, lotion, or solution.
  • Ciclopiroxolamine (Loprox) 1% shampoo, gel, or cream.
  • Zinc pyrithione (keratolytic/antifungal) shampoo or cream.
• Topical corticosteroids are generally effective and may be used in combination with topical antifungal therapy (see above). Low-potency agents (eg, hydrocortisone 1%) rather than high-potency corticosteroids (eg, betamethasone dipropionate, triamcinolone), are recommended, especially for the face, to reduce the adverse effects associated with all corticosteroids (eg, atrophy, telangiectasias, and perioral dermatitis).
• Selenium sulfide/sulfur preparations (the most common is selenium sulfide shampoo).
• Whole coal tar and crude coal tar extract.
• Lithium succinate ointment, available in some countries as a combination of 8% lithium succinate and 0.05% zinc sulfate (may have antifungal or anti-inflammatory effects).
• Antibiotic agents:
  • Metronidazole 1% gel
• Honey, 90% diluted with warm water, may be useful to treat seborrheic dermatitis and dandruff.
• Noncorticosteroid topical immunomodulators (eg, tacrolimus, pimecrolimus) are helpful in atopic dermatitis and may be useful for seborrheic dermatitis.
• Oral therapy may be used for patients refractory to topical treatment (check for possible drug-drug interactions with antiretroviral and other medications before prescribing).
  • Itraconazole 200 mg once daily for 7 days (safest and best option)
  • Ketoconazole 200 mg once daily for no more than 4 weeks (prolonged use may cause hepatotoxicity)
  • Terbinafine 250 mg once daily for 4 weeks

Patient Education

• Although topical and oral medicines can relieve symptoms, recurrence of symptoms is common. Effective antiretroviral therapy also should be considered to control the effects of HIV on the immune system and thereby treat the underlying cause of seborrheic dermatitis.

References

• Dunic I, Vesic S, Jevtovic DJ. Oral candidiasis and seborrheic dermatitis in HIV-infected patients on highly active antiretroviral therapy. HIV Med. 2004 Jan;5(1):50-4.
• Faergemann J, Bergbrant IM, Dohse M, et al. Seborrhoeic dermatitis and Pityrosporum (Malassezia) folliculitis: characterization of inflammatory cells and mediators in the skin by immunohistochemistry. Br J Dermatol. 2001 Mar;144(3):549-56.
• Gupta AK, Bluhm R. Seborrheic dermatitis. J Eur Acad Dermatol Venereol. 2004 Jan;18(1):13-26; quiz 19-20.
• Gupta AK, Ryder JE, Nicol K, et al. Superficial fungal infections: an update on pityriasis versicolor, seborrheic dermatitis, tinea capitis, and onychomycosis. Clin Dermatol. 2003 Sep-Oct;21(5):417-25.
• Rigopoulos D, Paparizos V, Katsambas A. Cutaneous markers of HIV infection. Clin Dermatol. 2004 Nov-Dec; 22(6):487-98.