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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Organ System>
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Seborrhea

Spyridon S. Marinopoulos, M.D.
04-16-2009

  • Seborrhea is ubiquitous problem and likely to be common in HIV+ patients in Zambia.
  • However, there are only limited reports on specific epidemiology in Zambia.
  • Dx of seborrhea typically made clinically; treatment similar to developed world.
  • Ciclopirox gel, terbinafine, accutane, pimecrolimus, and phototherapy not readily available in Zambia.

REFERENCES

Zambia Information Author: Larry William Chang, MD, MPH

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

General Principles

  • 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.
TOPICAL

  • 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
SYSTEMIC

  • 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

DrugRecommendations/Comments
Itraconazole Choose when seborrhea diffuse, resistant to topical Rx or when chronic topical steroids must be avoided. Does not have same potential to cause hepatotoxicity as ketoconazole; may be safer alternative for pts who require PO Rx, but drug interactions may be a problem.
IsotretinoinTeratogenic. Adverse effects include hyperlipidemia, neutropenia, anemia and hepatitis. Use only in severe, refractory cases.
Ketoconazole Increased side-effect risk (esp. hepatotoxicity) when used >4 wks. Many drug interactions. Absorption less reliable, especially with advanced HIV disease.
Terbinafine Alternative oral agent. Hepatotoxicity risk.

OTHER INFORMATION

  • Recommendations represent author opinion.

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