History

Fact Explanation
Skin lesion Seborrheic dermatitis is a chronic or relapsing papulosquamous inflammatory disease of the skin. The exact pathophysiology is unknown, but is thought to be due to inflammation induced by metabolites of the proliferating Malassezia furfur, which is a commensal. It mainly affects the scalp and face. It is generally confined to areas where sebaceous glands are most prominent. So, the rash is often prominent around the ear, the eyebrows or the eyelids. With time, it may spread to affect armpit and groin folds. Infantile seborrhoeic eczema affects infants under the age of 3 months. An intermittent active phase (flare) is characterized by gradually appearing diffuse or patchy, greasy scaling on scalp (Cradle cap). The scaly lesion is yellowish in color. Crusting is formed due to secondary infection. It is usually not itchy and does not bother the baby. Seborrheic dermatitis usually resolves by 6–12 months of age. [1,2,3,4,5]
Dandruff In older children seborrheic dermatitis can present as dandruff. This is characterized by a fine, powdery white scale on the scalp. Many patients complain of the scalp itching with dandruff. Besides an itchy scalp, patients may complain of a burning sensation in affected facial areas. [2,3,4]
At risk population Infantile seborrhoeic dermatitis is common among the babies under the age of 3 months. Oily skin (seborrhoea), family history of psoriasis and immunosuppression may predispose. [1,2,5]
References
  1. GARY G. Optimizing treatment approaches in seborrheic dermatitis. J Clin Aesthet Dermatol [online] 2013 Feb, 6(2):44-9 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23441240
  2. BIELAN B. What's your assessment? Severe seborrheic dermatitis. Dermatol Nurs [online] 2008 Dec, 20(6):454, 472 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19241741
  3. DAS A, DAS NK. Cradle cap. Indian Pediatr [online] 2014 Jun, 51(6):509-10 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24986302
  4. BRODIE HR. A TREATMENT FOR SEBORRHEA CAPITIS (CRADLE CAP). Can Med Assoc J [online] 1964 Jan 18:136-7 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14118686
  5. SACHDEVA M, KAUR S, NAGPAL M, DEWAN SP. Cutaneous lesions in new born. Indian J Dermatol Venereol Leprol [online] 2002 Nov-Dec, 68(6):334-7 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17656992

Examination

Fact Explanation
Scaly skin lesion Infants present with a mild, patchy scaling to widespread, thick, adherent crusts in the scalp area. The lesion may be spread to the areas like forehead, the posterior part of the neck, the postauricular skin, eyebrows or the eyelids. The distribution is classically symmetrical. Child seems unaffected by the lesion. [1,2,3,4]
Plaque skin lesion More severe seborrheic dermatitis is characterized by erythematous plaques frequently associated with powdery or greasy scale in the scalp and behind the ears. [3,4,5]
References
  1. DAS A, DAS NK. Cradle cap. Indian Pediatr [online] 2014 Jun, 51(6):509-10 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24986302
  2. GARY G. Optimizing treatment approaches in seborrheic dermatitis. J Clin Aesthet Dermatol [online] 2013 Feb, 6(2):44-9 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23441240
  3. BRODIE HR. A TREATMENT FOR SEBORRHEA CAPITIS (CRADLE CAP). Can Med Assoc J [online] 1964 Jan 18:136-7 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14118686
  4. SACHDEVA M, KAUR S, NAGPAL M, DEWAN SP. Cutaneous lesions in new born. Indian J Dermatol Venereol Leprol [online] 2002 Nov-Dec, 68(6):334-7 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17656992
  5. BIELAN B. What's your assessment? Severe seborrheic dermatitis. Dermatol Nurs [online] 2008 Dec, 20(6):454, 472 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19241741

Differential Diagnoses

Fact Explanation
Lichen Simplex Chronicus Lichen simplex chronicus (neurodermatitis) is a localized area of chronic, lichenified eczema/dermatitis. Patient usually has an underlying skin condition that results in repetitive scratching or rubbing. Though the exact pathophysiology is unknown, it makes the affected skin markedly thickened. There may be several affected areas in the body. The site are usually those which can be easily reachable such as nape of neck, scalp, extensor forearms and elbows, vulva and scrotum, upper medial thighs, knees, lower legs, and ankles. A solitary plaque of lichen simplex is circumscribed, somewhat linear or oval in shape. Surface is dry and hard. The area is intensely itchy. This is usually due to the underlying skin conditions. Rarely psychological issues may also involve. Itching is more intense at rest than when the patient is active. So, it is more common at night. Patient may complain of sleep disturbances. Itching may be habitual as well. [1]
Nummular Dermatitis Discoid eczema or nummular dermatitis is a recurrent or chronic form of eczema that can affect at any age though it is more common in 6th decade of life and affects males and females equally. The exact cause is still unknown and is thought to be strongly associated with skin dryness. The disease is characterized by distinct, coin-shaped (nummular) or oval blistered or dry skin lesions. Nummular dermatitis often starts off after minor skin injuries. Patient may have a days-to-months' history of rash. Lesions starts as small raised bumps (papules) or small fluid-filled blisters less than 1cm in diameter (vesicles). Then they unit in to form palpable flat lesion usually greater than 1 cm diameter. (plaques). One or many plaques appear, and may persist for weeks or months. The plaques are pink, red, or brown and well defined. Rashes can affect any part of the body, but the legs and buttocks are the most common areas. They usually occur symmetrically. [2]
Tinea Capitis Tinea capitis (ringworm) is the name used for infection of the head or scalp with a dermatophyte fungus. Tinea may be acute (sudden onset and rapid spread) or chronic (slow extension of a mild, barely inflamed, rash). It usually affects exposed areas but may also spread from other infected sites. [3]
Atopic Dermatitis Atopic dermatitis is a relapsing chronic skin disorder with an immunologic basis. The clinical presentation varies from mild to severe. It may interfere the normal growth and development in worst case scenarios. Major characteristics include pruritus, typical morphology and distribution (linearity and flexural lichenificationin adults, extensor and facial involvement in young children and infants), chronic or chronically relapsing dermatitis and personal or family history of atopy. [4]
Psoriasis Psoriasis is a chronic inflammatory skin disease caused by hyperproliferation of the keratinocytes in the epidermis. It is characterized by worsening of a long-term erythematous scaly area. This is most common on the elbows, extensor surfaces of the knees, scalp and trunk. The lesion is mostly itchy and painful. Skin lesion is accompanied with dystrophic nails, arthropathies and ocular manifestations such as blepharitis. Psoriasis can begin at any age, but not very common in infants. This is quite different from Seborrhoeic dermatitis which is common below one tears of age, occurs more commonly on the scalp as a painless and non itching scaly lesions that rarely form plaques. Seborrhoeic dermatitis is not accompanied by manifestations other than in skin. [5]
References
  1. PRAJAPATI V, BARANKIN B. Dermacase. Lichen simplex chronicus. Can Fam Physician [online] 2008 Oct, 54(10):1391-3 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18854464
  2. IAMTON S, TANGJATURONRUSAMEE C, KULTHANAN K. Clinical features and aggravating factors in nummular eczema in Thais. Asian Pac J Allergy Immunol [online] 2013 Mar, 31(1):36-42 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23517392
  3. BACHMEYER C, BUOT G. Tinea corporis in a mixed martial arts fighter. CMAJ [online] 2013 Jul 9, 185(10):897 [viewed 28 July 2014] Available from: doi:10.1503/cmaj.120813
  4. YOO J, MANICONE AM, MCGUIRE JK, WANG Y, PARKS WC. Systemic sensitization with the protein allergen ovalbumin augments local sensitization in atopic dermatitis. J Inflamm Res [online] 2014:29-38 [viewed 06 August 2014] Available from: doi:10.2147/JIR.S55672
  5. DUBOIS DECLERCQ S, POULIOT R. Promising new treatments for psoriasis. ScientificWorldJournal [online] 2013:980419 [viewed 26 August 2014] Available from: doi:10.1155/2013/980419

Investigations - for Diagnosis

Fact Explanation
Histology Diagnosis of Seborrheic dermatitis is clinical. Skin biopsy may be helpful but is rarely indicated. Microscopic presence of Malassezia is not diagnostic as it is a normal component of the skin flora. Findings in the histology specimen are nonspecific. acanthosis, Acanthosis, hyperkeratosis, parakeratosis, accentuated rete ridges, and focal spongiosis can be seen. [1,2,3]
References
  1. GARY G. Optimizing treatment approaches in seborrheic dermatitis. J Clin Aesthet Dermatol [online] 2013 Feb, 6(2):44-9 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23441240
  2. BRODIE HR. A TREATMENT FOR SEBORRHEA CAPITIS (CRADLE CAP). Can Med Assoc J [online] 1964 Jan 18:136-7 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14118686
  3. SACHDEVA M, KAUR S, NAGPAL M, DEWAN SP. Cutaneous lesions in new born. Indian J Dermatol Venereol Leprol [online] 2002 Nov-Dec, 68(6):334-7 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17656992

Management - General Measures

Fact Explanation
Patient education Parents should be educated to care about the patient’s hygiene. Frequent cleansing of the commonly affected areas during the remission has been found to reduce the recurrences as the cleansing with soap removes oils and improves seborrhea. Treatment other than gentle washing is frequently not necessary in most mild cases. Outdoor recreation, especially during summer, will also improve seborrhea, although caution should be taken to avoid sun damage. [1,2,3]
References
  1. DAS A, DAS NK. Cradle cap. Indian Pediatr [online] 2014 Jun, 51(6):509-10 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24986302
  2. SACHDEVA M, KAUR S, NAGPAL M, DEWAN SP. Cutaneous lesions in new born. Indian J Dermatol Venereol Leprol [online] 2002 Nov-Dec, 68(6):334-7 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17656992
  3. BRODIE HR. A TREATMENT FOR SEBORRHEA CAPITIS (CRADLE CAP). Can Med Assoc J [online] 1964 Jan 18:136-7 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14118686

Management - Specific Treatments

Fact Explanation
Gentle washing In many cases gentle washing the affected area with gentle rubbing is sufficient. Rubbing removes the scales. The lesion usually resolves spontaneously. Gentle eyelash cleaning with both baby shampoo and cotton applicators is effective in Seborrheic blepharitis. [1,2,3,4]
Topical antifungal agents Topical antifungals such as ketoconazole/ ciclopirox/ clotrimazole can be applied as shampoo or cream to the scalp area of the infant. [1,3,5]
Zinc pyrithione Some strains of Malassezia are resistant to azole antifungals. In such instances zinc pyrithione can be effective. Selenium sulphide is another alternate. [3,4,5]
Tar Tar cream can be applied to scaling areas and removed several hours later by shampooing. Coal tar preparations may be used to remove dense scale. [1,2,3]
Topical corticosteroids Mild topical corticosteroids (Hydrocortisone) can be used for short intervals such as for 1-3 weeks to reduce inflammation in acute flares. Long term use of these steroids should be discouraged as they may increase the recurrence rate and foster dependence due to the rebound effect. [1,3,5]
Topical calcineurin inhibitors Topical calcineurin inhibitors such as pimecrolimus and tacrolimus are effective in refractory cases. They are available as creams or ointments. [1,2,4]
References
  1. DAS A, DAS NK. Cradle cap. Indian Pediatr [online] 2014 Jun, 51(6):509-10 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24986302
  2. BRODIE HR. A TREATMENT FOR SEBORRHEA CAPITIS (CRADLE CAP). Can Med Assoc J [online] 1964 Jan 18:136-7 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14118686
  3. SACHDEVA M, KAUR S, NAGPAL M, DEWAN SP. Cutaneous lesions in new born. Indian J Dermatol Venereol Leprol [online] 2002 Nov-Dec, 68(6):334-7 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17656992
  4. GARY G. Optimizing treatment approaches in seborrheic dermatitis. J Clin Aesthet Dermatol [online] 2013 Feb, 6(2):44-9 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23441240
  5. BIELAN B. What's your assessment? Severe seborrheic dermatitis. Dermatol Nurs [online] 2008 Dec, 20(6):454, 472 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19241741