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Seborrheic dermatitis: symptoms, incidence, treatment

by Josephine Andrews
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Seborrheic eczema (seborrheic dermatitis) is a chronic inflammatory, scaly skin rash. It occurs in areas of skin rich in sebaceous glands, especially on the head. The condition is treated with medications such as antifungals and corticosteroids. Read everything important about the cause, symptoms and diagnosis of the skin disease and how seborrheic eczema is treated!

ICD codes for this disease:

ICD codes are internationally valid codes for medical diagnoses. They can be found, for example, in doctor’s letters or on certificates of incapacity for work.

L21

Seborrheic eczema: description

Seborrheic eczema (seborrheic dermatitis) is a yellow, scaly, red skin rash (eczema) in the area of ​​the sebaceous glands (seborrheic). These produce sebum – a mixture of fats and proteins that protects the skin from drying out. The sebaceous glands are primarily located in the front ( chest ) and rear (back) sweat ducts, on the face and on the hairy head. These are therefore also the preferred places of origin of seborrheic eczema. The scalp is also the area most commonly affected by the skin disease in infants – hence its second name “cranial gneiss”.

Seborrheic eczema should not be confused with seborrheic keratosis, which is also known as age warts .

Seborrheic dermatitis: frequency

Three to five percent of people develop seborrheic dermatitis every year. If one includes mild cases that do not require treatment, however, this number would probably be significantly higher. Men between the ages of 30 and 60 are most frequently and severely affected by the skin disease. Seborrheic eczema occurs particularly often in connection with HIV infection (especially in the AIDS stage) and Parkinson’s disease .

The form that occurs in infants in the first few weeks of life (up to two years of age at the very latest) is less common than seborrheic eczema in adults.

Seborrheic dermatitis: symptoms

Seborrheic eczema is characterized by mostly clearly defined reddening of the skin with yellowish scales. Depending on the severity of the disease, however, the skin symptoms are very variable: some patients only have increased skin flaking, while others suffer from massive skin inflammation. The infestation can also be localized or spread to several skin regions. The scales often feel greasy.

Seborrheic dermatitis most commonly occurs on the head. In addition, the face and the anterior and posterior sweat grooves are typical localizations. Inflammation of the eyelids ( blepharitis ) can also occur.

As a rule, seborrheic eczema does not cause pain and only rarely causes itching. However, the damaged skin areas can become infected with bacteria and fungi. Scratch marks as a result of severe itching then damage the skin further.

In rare cases, seborrheic dermatitis can lead to hair loss . Such hair loss is usually associated with eczema, but not caused by it.

Seborrheic dermatitis: Different forms

There are different forms of seborrheic eczema:

The Seborrheic Eczematid

In contrast to this, the focal seborrheic dermatitis is characterized by fully developed symptoms: the “foci” are clearly reddish inflamed, irregular and yellowish scaly. This form of the disease is often chronic and relapsing (with relapses).

A so-called intertriginous localization is listed by some experts as a subtype of seborrheic eczema. Areas on the body where opposing surfaces of skin touch or may touch directly are referred to as intertriginous. These are, for example, the armpits, the area under the female breast, navel, groin and anus. In these cases there is a high risk of infection. However, seborrheic eczema in these areas can also be confused with a pure fungal infection (usually Candida).

Disseminated seborrheic eczema is particularly serious, which runs from subacute to acute (“subacute” = less acute/severe), It occurs either without an identifiable cause or after irritation of existing foci, for example through treatment that is not tolerated. The foci are often distributed symmetrically, are large, run together (confluent), are scaly and may also be characterized by larger weeping and crusting skin defects (erosions). In severe cases, the whole body is reddened (erythroderma).

A rare form of the disease is pityriasiform seborrheic dermatitis . It usually occurs on the torso. The “pityriasiform” part of the name indicates that this rash is very similar to pityriasis rosea. The foci are round-oval and confluent. Typically, the scaling is emphasized in the center. In contrast to erysipelas, there is no larger focus that appears first (the so-called primary medallion).

Seborrheic dermatitis in infants

Most babies with seborrheic eczema develop on their heads. This so-called “head gneiss” is characterized by thick, yellow greasy scales. In many cases, the condition begins in the crown of the head, near the eyebrows, on the cheek, or on the nose . From there, seborrheic eczema can spread to the entire scalp and face. The scaling can be very strong. The baby’s hair appears greasy and stringy.

As in adult patients, seborrheic eczema is usually not a problem for the affected infant, in contrast to so-called atopic eczema. The “head gneiss baby” seems satisfied. He usually eats and sleeps normally.

Sometimes Seborrheic Dermatitis spreads to the diaper area, groin, belly button, armpits, or less commonly, the chest. An infestation in different places is also possible. The spread of pathogens, especially fungi, leads to reddening of the skin and changed scaling in the marginal area. Disseminated forms of seborrheic dermatitis are rare.

Seborrheic dermatitis: causes and risk factors

Why some people develop seborrheic dermatitis is unclear. A genetic predisposition to the disease could make a contribution. Increased sebum production and excessive colonization of the skin with yeast fungi (such as Malassezia furfur , formerly known as Pityrosporum ovale ) are also discussed as (contributory) causes , to which the immune system reacts in a correspondingly irritated manner. According to the current study situation, however, seborrheic eczema can also develop without increased yeast colonization. Overall, it remains unclear which of the factors mentioned play the decisive role.

In any case, those affected have a disturbed renewal of the skin. New skin cells migrate to the surface, where they later die and are shed to make room for new skin cells. This process is not visible on healthy skin because the skin cells are very small. The disrupted skin renewal in seborrheic eczema, on the other hand, causes the typical large scales to form.

head gneiss

Residues of maternal hormones (androgens) play a role in infants with seborrheic eczema of the head : They drive the baby’s sebum production and thus support the development of “cranial gneiss”. In the first few months of life, however, these residues of maternal hormones are broken down in the baby’s body, after which sebum production returns to normal.

related to other diseases

Seborrheic eczema occurs more frequently with certain diseases. These include various neurological diseases, in particular Parkinson’s disease, as well as HIV infections:

Parkinson’s patients often suffer from increased sebum production, which promotes the development of seborrheic dermatitis.

Seborrheic dermatitis can be found in up to 83 percent of AIDS patients. The reason for this increased occurrence is unclear. Seborrheic eczema is one of the so-called skin signs of AIDS and is often severe and therapy-resistant in these patients: the disease is often larger and more severe in HIV-infected people than in non-infected people and can also extend to atypical skin areas. This is particularly true for those HIV patients in whom the number of T immune cells – the CD4+ (subgroup of T lymphocytes ) – is greatly reduced. After the start of therapy, seborrheic eczema can also be evaluated as a sign of a resurgent immune system in an HIV patient.

The so-called androgenic effluvium is also associated with seborrheic eczema – a form of hair loss that is caused by genetic hypersensitivity of the hair roots to male sex hormones (androgens).

Seborrheic dermatitis: influencing factors

A number of medications can cause a skin rash similar to seborrheic dermatitis. These include, for example, erlotinib, sorafenib and interleukin-2 (all cancer drugs). Treatment with so-called neuroleptics, which are used for various psychiatric diseases, can also promote the development of seborrheic dermatitis.

Stress and cold seem to make seborrheic dermatitis worse. In summer , on the other hand, the skin disease (under UV radiation) usually improves. However, the effect of UV light is controversial. Seborrheic eczema can also develop as a result of UV-A therapy – a form of light therapy – in psoriasis patients.

Seborrheic dermatitis: investigations and diagnosis

The specialist for seborrheic eczema is the skin doctor (dermatologist) or – in the case of infants – the pediatrician (pediatrician). First, the doctor will collect the medical history of the patient (anamnesis). Possible questions are:

  • How long have the skin symptoms existed?
  • Are the rashes itchy?
  • Have you had similar skin rashes in the past?
  • Are there any other diseases (like other skin diseases, HIV infection)?

Then follows a physical examination : the doctor carefully examines the relevant skin areas. Firstly, the localization and secondly the appearance of the skin symptoms are decisive criteria for the diagnosis of seborrheic eczema.

In the rare cases of doubt, the doctor can take a skin sample ( biopsy ) and have it examined by a pathologist. There are no specific signs of seborrheic eczema. Typically, however, one can see under the microscope a thickening of the prickly cell layer of the skin (acanthosis) due to increased formation of new skin cells, disturbed keratinization of the skin (parakeratosis), the immigration of immune cells and water retention ( spongiosis). In addition, there are more immune cells in diseased skin than in healthy skin.

The microscopic picture of the skin sample can resemble psoriasis (psoriasiform) or erysipelas (pityrasiform), especially in chronic cases. In the case of an existing HIV infection, the microscopic picture of the skin symptoms can be different.

Seborrheic eczema: differentiation from other diseases

Seborrheic eczema must be differentiated from diseases with similar symptoms (differential diagnoses). These include, for example:

  • Atopic dermatitis (neurodermatitis)
  • contact eczema
  • Psoriasis, also known as psoriasis capitis (psoriasis on the scalp)
  • Branworm ( Pityriasis versicolor )
  • Rose lichen (Pityriasis rosea)
  • other skin fungal infections (like head fungus = tinea capitis)
  • Impetigo contagiosa (infectious, bacterial skin disease in childhood)
  • Rosacea (Rosacea)

Other diseases that can cause skin symptoms similar to seborrheic dermatitis are lupus erythematosus , lues ( syphilis ) and head lice .

In infants, the pediatrician must distinguish seborrheic dermatitis from ” cradle cap ” (atopic dermatitis). In this condition, the scalp is noticeably red, weeping, and crusted. In addition, the affected children seem to feel severe itching. Cradle cap usually occurs later than infant seborrheic eczema.

If the rash is particularly prominent in the diaper area, it may be diaper thrush — a fungal infection caused by the yeast Candida.

Seborrheic dermatitis: treatment

Seborrheic eczema often has to be treated because of its usually chronic course – externally and, if necessary, internally (taking medication).

The treatment is based on skin care and stress reduction . The most important therapeutic agents are antifungal drugs ( antimycotics ) and corticosteroids (“cortisone”). Even shaving can be helpful in the beard area.

If the patient also suffers from underlying diseases such as Parkinson’s or HIV, treating them can improve the complexion.

Treating seborrheic eczema takes patience. However, if the rash persists despite adequate treatment, the diagnosis of seborrheic dermatitis should be reconsidered.

Seborrheic dermatitis: topical therapy

The external treatment is usually long-term and is aimed primarily at sebum production, inflammation and infections. The various applications can usually be combined with one another.

Principle of treatment should be good skin care. Use non-alkaline detergents. They are intended to promote degreasing of the skin and prevent infections.

keratolytics

Seborrheic eczema on the head can be treated well with special shampoos that dissolve the dandruff and help against infections. Selenium , zinc , urea , tar , salicylic acid , chloramphenicol and ethanol are among the active ingredients in shampoos for seborrheic dermatitis. The shampoo is usually applied two to three times a week in the evening. You wrap a bandage around your head overnight and wash your hair in the morning.

Possible side effects are primarily local reactions such as itching, burning and changes in the color of the hair or scalp.

antifungal

Seborrheic dermatitis is often treated with a cream containing antifungal (antifungal) drugs such as ketoconazole or ciclopirox . These reduce skin colonization with the Malassezia yeast and the inflammatory reaction. Antifungal agents are also available as hair tinctures or shampoos. You can find detailed instructions for use in the package leaflet or you can get it from your doctor or pharmacist.

Possible side effects are local irritation and burning. Serious side effects from the topical application of antifungal shampoos or ointments are rare.  

corticosteroids 

Seborrheic eczema can also be treated briefly with preparations containing cortisone (eg as a shampoo, lotion or foam). It is important to start treatment with the lowest possible potency cortisone preparations. In comparison to the antimycotic drugs, the use of cortisone has turned out to be of equal value. Cortisone also helps against any existing itching. Inflammation of the eyelids (blepharitis) in the context of seborrheic eczema is usually treated with cortisone (and antibiotics if necessary).

Calcineurin Inhibitors

The treatment of seborrheic eczema with so-called calcineurin inhibitors (pimecrolimus, tacrolimus), for example in the form of an ointment, is considered to be just as effective as antimycotics and corticosteroids. These drugs directly inhibit the immune system. However, the application should only be short-term or as an interval treatment, since cases of tumors (especially lymphomas and skin tumors) have been described.

antibiotics

Seborrheic eczema is only treated with antibiotics if there is also a clear bacterial infection.

lithium

Seborrheic eczema can also be treated with lithium ointments. Their positive effect is probably based on an anti-inflammatory effect. However, lithium supplements should not be used on the head.

Seborrheic dermatitis: Internal therapy

Internal use of medication can be indicated above all if the disease is in the disseminated variant or if seborrheic eczema shows a clear tendency to spread. Even if the external treatment does not work (sufficiently) or more than three skin areas are affected, internal treatment with cortisone or antimycotics can be considered. In addition, especially in patients with an HIV infection, seborrheic eczema can often be treated internally at an early stage and for a longer period of time.

Antifungal medications are usually taken for a week, on a daily basis. This is usually followed by follow-up treatment (eg two applications per month for three months).

Taking antibiotics is only indicated if the skin also shows a bacterial infection.

As a last resort to inhibit sebum production, doctors may prescribe isotretinoin – a derivative of vitamin A that is actually used to treat severe acne .

treatment in infants

Since the “head gneiss” usually heals spontaneously, treatment is not absolutely necessary. The best way to remove the scales is to soak them with oil (such as almond or olive oil) overnight. The scales of the head gneiss can then be removed more easily the next day, for example with a comb. You can also use zinc-containing ointments. After that, the hair should be washed with a care shampoo. This procedure usually has to be repeated several times to effectively remove the dandruff.

If these measures do not help, the seborrheic eczema does not regress or instead even spreads, you should take your child to the pediatrician. If necessary, they can prescribe, for example, local antifungal treatment twice a week for two weeks or a cortisone cream once a day for a week. Short-term treatment with local corticosteroids is considered safe – even in children. If symptoms do not improve within a week, the diagnosis of seborrheic dermatitis should be reconsidered.

Seborrheic dermatitis: Homeopathy & Co.

There are a variety of alternative therapies for treating seborrheic eczema, for example homeopathy, Bach flowers, Schuessler salts, home remedies and medicinal plants. However, the concept of these alternative treatment methods and their specific effectiveness are controversial in science and have not been unequivocally proven by studies.

For example, bathing with wheat bran and oat straw extract is said to promote healing. Shale oils are also said to promote wound healing and also have an antimicrobial effect. Menthol and thymol can reduce itching. However, such treatments should be accompanied by an experienced therapist.

Home remedies have their limits. If the symptoms persist over a longer period of time, do not get better or even get worse, you should always consult a doctor.

Seborrheic dermatitis: disease course and prognosis

Seborrheic dermatitis in adults is often chronic and recurs after the medication is stopped. Because of this, therapy must often be repeated or continued continuously to prevent a flare-up.

Seborrheic eczema damages the skin’s protective barrier against infection. This promotes bacterial and fungal infections of the skin. These need to be monitored and treated appropriately to prevent the germs from progressing or spreading.

In rare cases, contact sensitization develops in the sense of an allergic reaction or seborrheic eczema turns into psoriasis (psoriasis vulgaris). With the help of modern therapy methods, however, seborrheic eczema can usually be controlled well.

infant

In most cases, the growth of an infant is not affected by “cranial gneiss”. The disease is therefore considered harmless. However, the skin condition can return within weeks or even months and then require re-treatment. Seborrheic eczema usually disappears on its own by the end of the second year of life at the latest.

Seborrheic eczema: avoid recurrence

To prevent recurrence of seborrheic eczema, repeated use of the medication described with breaks may be necessary. However, good skin care and stress reduction can also help prevent seborrheic dermatitis from flaring up again. A possible treatment concept would be the use of antifungal shampoos once a week, also as a face or body wash. Emollient shampoos can also be used without restriction to prevent Seborrheic Dermatitis from reoccurring . Long-term use of corticosteroids, on the other hand, is not recommended due to side effects (such as skin tissue atrophy).

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