Diagnosis>Organ System>

PATHOGENS

• Pityrosporum spp. (aka Malassezia) possible fungal pathogen (controversial).

CLINICAL

• Chronic skin inflammation. More prevalent in HIV (up to 83% incidence) than general population (~3% incidence). More prevalent and severe w/ HIV progression.
• Hx: itching, redness, flaking, skin irritation. PE: erythematous patches/plaques w/overlying yellow, greasy scales and crusts. Typically symmetrical affecting areas of higher sebaceous gland concentration. Commonly see on: hairy areas of head (scalp, scalp margin, eyebrows/lashes, mustache, beard), forehead, malar area, nasolabial folds, external ear canals, retroauricular creases. Also may affect the chest (presternal area), back and intertriginous areas (axillae, navel, groin, inframammary, anogenital).
• In mild cases, flaking dandruff may be only manifestation. More severe cases present w/erythematous plaques assoc w/thicker/yellowish powdery or oily scale eventually progressing to erythroderma.
• Disease associations: HIV, Parkinson's, mood disorders, chronic alcoholic pancreatitis, HCV, various cancers, some genetic disorders, dermatologic conditions (rosacea, blepharitis, acne vulgaris, pityriasis versicolor, pityrosporum folliculitis).
• DDx: atopic dermatitis, contact dermatitis, psoriasis, rosacea, superficial fungal infections.

DIAGNOSIS

• Clinical Dx based on characteristic features.
• Skin Bx: characteristic in HIV pts but rarely necessary.
• KOH prep to r/o tinea.

TREATMENT

• Use dandruff shampoo, topical antifungals and/or topical corticosteroids first line x 4 wks.
• If ineffective, may try more potent topical steroid, but limit use to 2 additional wks.
• If again ineffective, escalate to PO antifungals and consider referral to derm for definitive Dx.
• Refer to dermatology if Dx in doubt or no response to Rx or if PO isotretinoin contemplated.

• Ciclopirox gel 0.77% to affected area twice-daily x 4 wks or (if scalp affected) ciclopirox 1% shampoo biw x 4 wks (3d between applications).
• Ketoconazole 2% cream or shampoo twice-daily x 4 wks or until clear; may require weekly maintenance.
• Alternative: miconazole 2% cream once- or twice-daily x 4wks.
• Alternative: terbinafine 1% soln once-daily x 4 wks effective for scalp seborrhea.
• Alternative: metronidazole 1% gel twice-daily x 8 wks.
• Persistent pruritus: add topical steroid i.e. 1% hydrocortisone (HC) cream. If no effect, use betamethasone or triamcinolone 0.1% or fluocinonide or FS Shampoo (0.01% fluocinolone).
• Note: topical steroids alone may be effective, but generally used as adjunct to topical antifungals to avoid long-term steroid effects.
• Zinc pyrithione 1-2% shampoo (keratolytic + antifungal activity) or tar/coal tar shampoo or selenium sulphide shampoo 2.5% once-daily or every other day. Note: HIV-associated seborrhea may not respond to sulphur-containing soaps and creams.
• Sodium sulfacetamide/sulfur lotions applied twice-daily.
• Pimecrolimus 1% cream twice-daily x 4wks effective for facial seborrhea

• Note: use systemic Rx if lesions widespread or refractory to topical Rx.
• Ketoconazole 200 mg PO once-daily x 7-14d.
• Alternative: itraconazole 200 mg PO once-daily x 7d.
• Alternative: terbinafine 250 mg PO once-daily x 4 wk.
• Severe case refractory to other Rx: isotretinoin (Accutane) 0.1-0.3 mg/kg once -daily x 4 wks effective (acts by reducing sebum production). Side effects dictate cautious use. Teratogenic, counsel pts on an effective form of contraception.
• Phototherapy (UVB) tiw until complete clearing or to max 8 wks effective in some pts w/ severe disease.

Drug Comments

OTHER INFORMATION

• Recommendations represent author opinion.

REFERENCES