Spyridon S. Marinopoulos, M.D.
- 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.
Zambia Information Author: Larry William Chang, MD, MPH
Pityrosporum spp. (aka Malassezia) possible fungal pathogen (controversial).
- 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.
- Clinical Dx based on characteristic features.
- Skin Bx: characteristic in HIV pts but rarely necessary.
- KOH prep to r/o tinea.
- 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.
||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.
|Isotretinoin||Teratogenic. Adverse effects include hyperlipidemia, neutropenia, anemia and hepatitis. Use only in severe, refractory cases.
||Increased side-effect risk (esp. hepatotoxicity) when used >4 wks. Many drug interactions. Absorption less reliable, especially with advanced HIV disease.
||Alternative oral agent. Hepatotoxicity risk.
- Recommendations represent author opinion.