Topical Treatment of Facial Seborrheic Dermatitis: A Systematic Review.

BACKGROUND: Facial seborrheic dermatitis (SD), a chronic inflammatory skin condition, can impact quality of life, and relapses can be frequent. Three broad categories of agents are used to treat SD: antifungal agents, keratolytics, and corticosteroids. Topical therapies are the first line of defense in treating this condition. OBJECTIVE: Our objective was to critically review the published literature on topical treatments for facial SD. METHODS: We searched PubMed, Scopus, Clinicaltrials.gov, MEDLINE, Embase, and Cochrane library databases for original clinical studies evaluating topical treatments for SD. We then conducted both a critical analysis of the selected studies by grading the evidence and a qualitative comparison of results among and within studies. RESULTS: A total of 32 studies were eligible for inclusion, encompassing 18 topical treatments for facial SD. Pimecrolimus, the focus of seven of the 32 eligible studies, was the most commonly studied topical treatment. CONCLUSION: Promiseb®, desonide, mometasone furoate, and pimecrolimus were found to be effective topical treatments for facial SD, as they had the lowest recurrence rate, highest clearance rate, and the lowest severity scores (e.g., erythema, scaling, and pruritus), respectively. Ciclopirox olamine, ketoconazole, lithium (gluconate and succinate), and tacrolimus are also strongly recommended (level A recommendations) topical treatments for facial SD, as they are consistently effective across high-quality trials (randomized controlled trials).

Seborrheic dermatitis: an update.

Seborrheic dermatitis is a chronic relapsing inflammatory skin disorder clinically characterized by scaling and poorly defined erythematous patches. The prevalence of adult seborrheic dermatitis is estimated at 5%. Although the exact cause of seborrheic dermatitis has yet to be understood, Malassezia yeasts, hormones (androgens), sebum levels and immune response are known to play important roles in its development. Additional factors including drugs, winter temperatures and stress may exacerbate seborrheic dermatitis. A variety of treatment modalities are available, including antifungal agents, topical low-potency steroids and calcineurin inhibitors (immunomodulators). This review summarizes current knowledge on the etiopathogenesis and therapy of adult seborrheic dermatitis.

Double blind clinical trial in a series of 115 patients with seborrheic dermatitis: prevention of relapses using a topical modulator of Toll like receptor 2.

AIM: Seborrheic dermatitis is a chronic inflammatory disease aggravated by Malassezia species. Toll-like receptors (TLR) are part of innate immune system that can be activated by yeasts. Previous studies showed that an association of Umbelliferae extract with a lipid (TLR2-Regul™) decreases the IL-8 expression in human skin in contact with M. furfur. The aim of this study was to assess the activity of a topical formulated with TLR2-Regul™ in the prevention of seborrheic dermatitis (SD) relapses. METHODS: Immune-competent SD adult patients were treated for SD (topical imidazoles or steroids). Cleared patients were randomized and received a topical containing TLR2-Regul™ (A) or its vehicle (B). Erythema, scales and pruritus were assessed during two months. RESULTS: The study included 115 patients, mean age 43.4, sex ratio m/f 1.5. At week 4 the relapse rate was 26% (N.=15) in group A and 43% (N.=25) in group B. At W8 the relapse rate was 21% (N.=12) in group A and 40% (N.=23) (P=0.0309). CONCLUSION: In this series of 115 adults with seborrheic dermatitis, patients treated with a topical containing TLR-Regul™ showed a significantly less relapse rate compared with the excipient group (P<0.05). TLR modulation could represent a new therapeutic approach in the prevention of seborrheic dermatitis relapses.

Study of Monarda fistulosa essential oil as a prospective antiseborrheic agent.

Monarda fistulosa essential oil characterized by pronounced therapeutic effects is proposed for the treatment of seborrhea. Studies of its antibacterial, antimycotic, and antiinflammatory activities showed that it inhibits microorganism growth and is superior to hydrocortisone in combination with vitamin B6 by its antiinflammatory activity.

Malassezia globosa and restricta: breakthrough understanding of the etiology and treatment of dandruff and seborrheic dermatitis through whole-genome analysis.

Dandruff and seborrheic dermatitis (D/SD) share an etiology dependent upon three factors: sebum, microbial metabolism (specifically, Malassezia yeasts), and individual susceptibility. Advances in microbiological and analytical techniques permit a more detailed understanding of these etiologic factors, especially the role of Malassezia. Malassezia are lipid-dependent and demonstrate adaptation allowing them to exploit a narrow niche on sebum-rich skin. Work in our and our collaborators' laboratories has focused on understanding these adaptations by detailed analysis of biochemistry and gene expression. We have shown that Malassezia globosa and M. restricta predominate on dandruff scalp, that oleic acid alone can initiate dandruff-like desquamation, that M. globosa is the most likely initiating organism by virtue of its high lipase activity, and that an M. globosa lipase is expressed on human scalp. Considering the importance of M. globosa in D/SD (and the overall importance of commensal fungi), we have sequenced the M. globosa and M. restricta genomes. Genomic analysis indicates key adaptations to the skin environment, several of which yield important clues to the role Malassezia play in human disease. This work offers the promise of defining new treatments to D/SD that are targeted at changing the level or activities of Malassezia genes.

Role of antifungal agents in the treatment of seborrheic dermatitis.

Seborrheic dermatitis is a superficial fungal disease of the skin, occurring in areas rich in sebaceous glands. It is thought that an association exists between Malassezia yeasts and seborrheic dermatitis. This may, in part, be due to an abnormal or inflammatory immune response to these yeasts. The azoles represent the largest class of antifungals used in the treatment of this disease to date. In addition to their antifungal properties, some azoles, including bifonazole, itraconazole, and ketoconazole, have demonstrated anti-inflammatory activity, which may be beneficial in alleviating symptoms. Other topical antifungal agents, such as the allylamines (terbinafine), benzylamines (butenafine), hydroxypyridones (ciclopirox), and immunomodulators (pimecrolimus and tacrolimus), have also been effective. In addition, recent studies have revealed that tea tree oil (Melaleuca oil), honey, and cinnamic acid have antifungal activity against Malassezia species, which may be of benefit in the treatment of seborrheic dermatitis. In cases where seborrheic dermatitis is widespread, the use of an oral therapy, such as ketoconazole, itraconazole, and terbinafine, may be preferred. Essentially, antifungal therapy reduces the number of yeasts on the skin, leading to an improvement in seborrheic dermatitis. With a wide availability of preparations, including creams, shampoos, and oral formulations, antifungal agents are safe and effective in the treatment of seborrheic dermatitis.

Propionibacterium acnes lipase in seborrheic dermatitis and other skin diseases and Unsei-in.

We examined Propionibacterium acnes lipase in skin diseases and Unsei-in. Butyric acid production in axillary seborrheic dermatitis (ASD) was higher than in other dermatitis, and that in acne vulgaris (AV) was significantly higher than in controls. P. acnes lipase is the pathogenic factor in AV and fatty acids produced by lipase might be the pathogenic factor in ASD. Unsei-in suppressed P. acnes lipase probably because some ingredients have antimicrobial and anti-inflammatory activities.

Malassezia furfur: a fungus belonging to the physiological skin flora and its relevance in skin disorders.

Malassezia furfur is an anthropophilic fungus that belongs to the physiological skin flora. The fungus can grow in a yeast phase as well as in a mycelial phase; on nonaffected skin the fungus is mainly prevalent in the yeast phase. The organism has complex lipid requirements for growth, which also explains its occurrence on the skin. This also leads to the requirement for specially supplemented media for in vitro cultivation. Malassezia furfur is the causative agent of pityriasis versicolor. It also seems to be associated with seborrheic dermatitis and dandruff formation, folliculitis, confluent and reticulate papillomatosis, and the provocation of psoriatic lesions. Many substances for topical application, such as azole antimycotics, ciclopirox olamine, piroctone-olamine, zinc pyrithione, or sulfur-containing substances are effective in the treatment of these diseases. In recent years rare cases of systemic infections and fungemias caused by Malassezia have been reported.

Malassezia furfur in infantile seborrheic dermatitis.

Malassezia furfur is important in the pathogenesis of a number of dermatologic diseases including seborrheic dermatitis in adults. It has also recently been suggested that M. furfur might be the etiologic agent in infantile seborrheic dermatitis (ISD). We studied the presence of M. furfur in 21 children with the clinical diagnosis of infantile seborrheic dermatitis. Laboratory analyses showed aberrant patterns of essential fatty acids (EFA) in serum characterized by elevated levels of 18:1w9 and 20:2w6. Samples for M. furfur were taken from the foreheads and chests of children with infantile seborrheic dermatitis at the time of diagnosis, directly after treatment to complete healing, and after 1 year with no signs of infantile seborrheic dermatitis. All the patients were treated topically with borage oil containing 25% gammalinolenic acid (GLA). No reduced growth of M. furfur was seen on contact plates prepared with borage oil. The growth of M. furfur seems not to be related to the clinical symptoms in ISD.

[Effect of anti-seborrhea substances against Pityrosporum ovale in vitro]. / Der Effekt anti-seborrhoischer Substanzen gegenüber Pityrosporum ovale in vitro.

Thirty strains of the lipophilic yeast Pityrosporum ovale were isolated from patients suffering from seborrhoeic dermatitis and dandruff and tested for susceptibility both to some classic antifungal agents and to several primarily non-antimycotic drugs. Minimal inhibitory concentrations (MIC) of altogether eleven agents were measured by the agar dilution technique. As expected, the tested imidazoles showed a good inhibition of growth of Pityrosporum. The most effective agents were ketoconazole (MIC 0.1 microgram/ml) and itraconazole (MIC 0.05 microgram/ml for some strains). MIC for fluconazole, clotrimazole and tioconazole were also low, indicating a good inhibition of Pityrosporum. In contrast, the range of MIC for bifonazole was moderate to high (for some strains 12.5-25 micrograms/ml). For zinc pyrithion a very good in vitro efficacy (MIC 0.78-1.56 micrograms/ml) was dedicated. The MIC for selenium disulphide was 1.56-3.13 micrograms/ml. The antipsoriatic drugs dithranol and liquor carbonis detergens also inhibited growth of all Pityrosporum ovale strains investigated but only at higher concentrations.

An overview of experience with ketoconazole shampoo.

The spectrum of disease known as dandruff/seborrhoeic dermatitis has been shown to be due to infection of the skin by the Pityrosporon species of fungus. Ketoconazole shampoo has been shown to suppress effectively both the organism's growth and the symptoms and signs of the clinical disorder.

Role of microorganisms in dandruff.

The role of microorganisms in dandruff was studied, by suppressing individually and then collectively the three major components of the scalp microflora. The effect on dandruff was assessed subjectively by clinical grading and objectively by the corneocyte count. No effect on dandruff was demonstrated when scalp organisms were suppressed. In the second group of experiments, dandruff was suppressed by selenium sulfide shampooling and the effect of continued suppression of Pityrosporum with topically applied amphotericin was measured. According to our criteria, dandruff returned to pretreatment levels, despite continued suppression of Pityrosporum. The studies demonstrate that the increased number of scalp microorganisms found in dandruff occurs as a secondary event to increased nutrients and that scalp organisms play no primary role in the pathogenesis of dandruff.

Generalized seborrhoeic dermatitis. Clinical and therapeutic data of 25 patients.

Twenty-five infants with generalized seborrhoeic dermatitis have been studied with reference to the provision of optimum treatment. Leucocyte counts and chest x-ray examination are recommended in every case. Irrespective of clinical findings, antibiotics should be given to patients with overt bacterial infection and those with leucocytosis, shift to the left, and toxic granulation. One group of infants was treated with vitamin B complex plus biotin given slowly intravenously over 24 hours; a second group was given only biotin intravenously over 2-3 hours; and a third group only biotin over 1-2 minutes. A fourth group was treated with both biotin and antibiotics for confirmed or suspected superimposed bacterial infection. The results were excellent in all groups. Skin lesions improved within 4-8 days and cleared completely within 15-30 days. Intravenous administration of biotin is recommended as less painful and less dangerous than multiple intramuscular injections.