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Seborrheic Dermatitis

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Patient Story
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A 3-month-old African American boy is brought to the clinic with white spots on his face for one month (Figure 135-1). The child is otherwise in great health, eating well and gaining weight. The mother was negative for HIV during pregnancy. On physical exam, there are hypopigmented patches on the face especially at the hair line and under the eyebrows. There is visible scale in each of these patches. The hypopigmentation occurs secondary to the toxic effect of the Malassezia (Pityrosporum) on the melanocytes (as seen in tinea versicolor). The diagnosis of seborrheic dermatitis is made and treatment is begun with appropriate topical agents to treat the inflammation and the Malassezia. The mother is told to shampoo the infant’s hair with a selenium-based shampoo every 1 to 2 days and to apply 1 percent hydrocortisone cream to the hypopigmented areas twice daily for the next 2 weeks. At a 2-week follow-up, the scale is gone and the hypopigmentation is resolving.

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FIGURE 135-1

Seborrheic dermatitis on the scalp and face with visible hypopigmentation. Note how the hypopigmentation is particularly visible around the hairline and under the eyebrows. (Used with permission from Richard P. Usatine, MD.)

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Patient Story
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A 13-year-old African American boy presented to clinic with a mildly pruritic central facial rash and scalp dandruff that had persisted for two years (Figure 135-2). There was no history to suggest an allergic contact dermatitis or drug allergy. On physical exam, confluent scaling and erythema with areas of hypopigmentation were noted in the naso-mesial folds and over the eyebrows. Additionally, diffuse scaling and erythema were noted throughout the scalp. The patient was diagnosed with seborrheic dermatitis. Patients with more pigmentation often show a raised lateral margin reminiscent of the advancing border of dermatophyte infections and subsequent postinflammatory hypopigmentation that can be temporarily disfiguring. This patient responded to ketoconazole 2 percent cream applied twice daily to the face and other non-hair-bearing areas and ketoconazole 2 percent shampoo twice weekly for his scalp. His hypopigmentation improved over time.

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FIGURE 135-2

Seborrheic dermatitis in a 13-year-old boy demonstrating confluent scaling and erythema along with areas of hypopigmentation. Patients with more pigmentation often show a raised lateral margin reminiscent of the advancing border of dermatophyte infections and subsequent post-inflammatory hypopigmentation that can be temporarily disfiguring. (Image used with permission from Robert Brodell, MD.)

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Introduction
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Seborrheic dermatitis is a common, chronic, relapsing dermatitis affecting sebum-rich areas of the body. Children and adults, males and females may be affected. Presentation may vary from mild erythema to greasy scales, and rarelyas erythroderma. Treatment is targeted to reduce inflammation and irritation, as ...

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