Dandruff and Seborrheic Dermititis (complete) Flashcards
what is the medical term of dandruff?
pityriasis simplex capitis
what are 2 papulosquamous cutaneous disroders that may be difficult to distinguish from one another?
dandruff and seborrheic dermatitis (SD)
what is SD?
inflammatory condition with erythematous and scaling eruptions primarily in “seborrheic areas” (high number of sebaceous glands - scalp, face (eyelashes & brows, beard and mustache), and upper trunk)
what questions do you need to ask to assess dandruff and SD?
- onset, frequency, duration of symptoms
- area and extent of involvment
- description of skin lesions
- associated systemic symptoms?
- aggravating factors?
- current hygiene practices
- attempted treatments
when sudden onset in a young patient occurs, what needs to be ruled out?
cutaneous lymphoma, Langerhans cell histocytosis, HIV, etc.
what are the typically affected areas for SD?
hairy areas of the head (scalp, scalp margin, eyelashes, brows, beard, mustache);
nasolabial folds, forehead, outer ear canals and in the creases behind the ears (facial skin sites predisposed to SD are generally those with increased skin temperature);
SD of the torso may be present in the area of the sternum and in body folds (under the breasts, underarms, navel, groin, anogenital area)
what does SD look like?
It begins in small patches, rapidly spreading, with diffuse fine scales that in lightly coloured skin can be white, off-white or yellow with no signs of acute dermatitis such as oozing or weeping.
Exudation may be seen in facial SD from time to time. In darkly coloured skin, SD may appear as scaly, hypopigmented macules and patches in typical areas of involvement. Arched or petal-shaped patches may be seen.[12] SD typically flares and resolves in a cyclic or seasonal fashion, often in response to stress.[1]
for infants, the entire scalp may be covered with thick, dry, adherent, yellowish-brown scales overlying erythema, often called cradle cap. what can you tell mom?
cradle cap is self-limiting, appear in 1-4 weeks of life, usually disappears after first 3 months.
Scalp SD must be distinguished from what condition?
dandruff, psoriasis, tinea capitis, atopic dermatitis, rosacea, systemic lupus erythematosus, fungal skin infections
when do you have to refer SD patients?
when diagnostic uncertain,
when first line treatment failure after 4 weeks
The development of SD is thought to be related to …
hormone levels, increased sebum production and skin lipid composition.
Factors that increase risk of developing SD or provoking flares include:
-genetic
-HIV
-nerologic condition (Parkinson disease, cranial nerve palsies, mojor truncalparalyses)
-pityriasis versicolor, psychiatric disorders, alcoholic pancreatitis or hepatitis C, hyperandrogen syndromes in females
-middle-age or elderly (most common inflammatory skin conditions in these patients)
-environmental factors (change in humidity or cold and dry weather)
-infection stress, sleep deprivation, sweat, emotional stress
-diet (western diet)
what are the drugs known to trigger SD?
Arsenic
Ethionamide
Auranofin
Gold
Methyldopa
Buspirone
Penicillamine
Chlorpromazine
Haloperidol
Phenothiazines
Cimetidine
Interferon, alfa
Psoralens
Danazol
Lithium
what is the common sites of psoriasis?
scalp, elbows, knees, sacrum
what is the common site for SD?
central face, scalp, mid-chest
SD - skin fold involvement?
yes - inverse type, glans penis, mostly infants
does SD itchy?
varies - more common with involvement of scalp or ear canal
does psoriasis itchy?
sometimes
for baby SD, what are non-pharm measures?
frequent cleansing with mild, nonmedicated shampoo;
gentle brushing on the scalp with a soft baby brush
what is non-pharm measure for SD?
avoid irritating soaps, heavy gels, hairsprays and greasy creams;
keep hair short / beard trimmed;
avoid use of excessively hot water;
use a cool air humidifier ro dish of water to add moisture to the indoor environment and prevent provocation of symptoms due to dry air;
exposure of the affected area to sunlight and warm weather;
treat eyelid with warm to hot compresses and wash with diluted baby shampoo or specialized eyelid cleansing products, followed by gentle cotton tip removal of thick scales;
frequent shampooing at least 3 times weekly is key to controlling symptoms;
shampoos with surfactants (e.g. sodium lauryl sulfate) and detergents are better able to remove unsightly scales and will elad to clinical improvement and decreased scaling.
Pharmacological treatment of dandruff and SD generally consists of three classes of medications. what are they?
antifunal,
anti-inflammatory,
keratolytics
how to use medicated shampoo for SD?
massage shampoo into the scalp for 4-5 minutes;
rinse thoroughly;
part their hair in small sections, and apply and massage the medicated shampoo or scalp treatment into the scalp at the hair roots;
medicated therapies should be left in contact with the scalp or beard for 2-20 minutes depending on the product.
for more severe cases, therapies can be left on overnight under a shower cap;
shampoos may be used on the scalp, beard and chest but may cause the disease to flare if used on the face or other intertriginous areas for extended periods
what are the antifungals that can be used for SD?
ketoconazole, clotrimazole, miconazole, ciclopirox olamine, selenium sulfide, zinc pyrithione, oral antifungals
what are disadvantages of selenium sulfide? when should you consider using it?
limited evidence of efficacy, more side effect (burning and itching scalp) - use when other treatments are ineffective
when do you use zinc pyrithione?
mild cases of dandruff or scalp SD only - evidence of efficacy is limited and of low quality
when do you use oral antifungals?
severe or refractory cases
what is the oral antifungal medication and dose?
itraconazole 200mg qd for 2 days per month - pulsed dosing –> higher efficacy and lower recurrence rates over 4 months
(ketoconazole associated with more relapses)
when do you rx topical corticosteroid?
if the response is not adequate or the lesions are extensive or severe;
with antifungal.
topical steroid for face or folds?
1% hydrocortisone
severe and thick scales on the scalp - what to do with topical steroid?
overnight application followed by shower cap occlusion
what is undesirable side effect from steroid topical?
atrophy, telangiectasia, poor wound healing, perioral dermatitis, pustular acne
what can be used to remove dense scales before applying topical steroids?
keratolytic such as salicylic acid or coal tar preparations
what dose keratolytics do?
loosen bonds between keratinocytes in the skin, helps detach flakes and increase penetration of other topical medications
what are the keratolytic agents available?
salicyclic acid, sulfur, coal tar
what are the characteristics of salicylic acid and sulfur and coal tar?
salicylic acid & sulfur - mildly effective due to keratolytic and antiseptic activities, but have minimal proven antifungal activity. Together is more potent, but are more irritating; therefore, proper use is important
coal tar - mildly effective, reduce local swelling and inflammation and relieves itching. reduce cell proliferation - requires time to lengthen cell differentiation and mormalize epidermal differentiation, resulting in a slow decline in visible scales. minimal antifungal activity. but odour, staining and concerns about side effects, includign possible carcinogenicity and reduced effectiveness compared to other agents .
for severe or refractory cases, what other alternatives have been used?
topical metronidazole;
sodium sulfacetamide 10% lotion alone or in combination with topical steroid;
lithium topical (compound) were reported effective- can be considered for recalcitrant cases;
low-dose systemic isotretinoin;
antiandrogen therapy (e.g. spironolacone, flutamide, cyproterone); UV light;
nicotinamide 4% cream, a shampoo containing lipohydroxy acid and salicylic acid, solution containing urea, lactic acid and propylene glycol have shown some efficacy.
what are some natural health products for SD?
quassia amara gel;
tea tree oil;
aloe vera;
solanum chrysotrichum
what is basic treatment wihtout medication for SD?
- decrease trigger factors
- avoid harsh soap, detergents, hairstyling products, greasy skin creams
- use warm water to bathe and remove scales each day
- use a regular shampoo daily (preferably one indicated for dry hair)
if ineffective for basic measures without med, what is the first line?
try 2 or more antifungal shampoos (ciclopirox, ketoconazole, selenium sulfide, zinc pyrithione) - 2-4 times weekly until control is achieved;
if effective, taper down to use once weekly or biweekly to maintain control
if firstline fails, what is next to treat SD?
- add keratolytic agent (salicylic acid +- sulfur)
- soften scales overnight (various oils or bath oils)
- add an antiproliferative agent (coal tar)
- add hydrocortisone for 1-3 weeks (use lotion for oily areas, creams if excessive drying results)
if 2nd line fails, then?
more potent topical corticosteroids, topical clacineurin inhibitors, topical lithium, systemic antifungals
how to apply Loprox shampoo for scalp?
2-3 times weekly or as often as necessary;
wet hair -> part a small section -> rub into scalp at the roots -> repeat until entire head has been treated -> leave on for at least 5 min then rinse
how quickly the loprox cream or shampoo works?
requires 2-3 weeks to see onset of effect
what is the side effect of loprox?how to use Nizoral shampoo?
use 2-4 times weekly;
same as loprox shampoo
how to use selenium sulfide (Selsun Blue, Head and Shoulders, Clinical Strength, others) shampoo?
use twice per week for 2 weeks, and afterwards use at less frequent intervals - do not use more than 3 times / week
same instruction as nizoral or loprox shampoo
what is the side effect of selenium sulfide?
if use too much, can have oily hair and hair loss.
sting if applied to broken skin.
may discolor bleached, tinted or permed hair - avoid use within 2 days;
avoid contact with any jewelry as it may be damaged.
how to use zinc pyrithione shampoo (head and shoulders, Z-plus shampoo, others)?
2-3 times weekly or as often as necessary;
what are calcineurin inhibitors (topical) available for SD?
Elidel (pimecrolimus)
Protopic (tacrolimus)
what is the dose of calcineurin inhibitors for treatment and maintenance?
BID for treatment;
2 days/week for maintenance
what are corticosteroid & topical/keratolytic combination product available for scalp?
betamethasone valerate / salicyclic acid (lotion) - use daily or BID
what is the dosage of salicylic acid (Dermarest, Sebcur, others) shampoo?
up to twice weekly.
what is the dosage of sulfur (Sulfur8) shampoo?
at least 2 times weekly, massaging thoroughly into affected area.
