Dandrugg and seborrheic dermatitis Flashcards
what is dandruff and seborrheic dermatitis
- Dandruff (pityriasis simplex capitis) and seborrheic dermatitis (SD) are papulosquamous cutaneous disorders
- both cause scaling associated with itching
- dandrugg is a milder non inflammatroy form of SD and is limited to scalp
- SD is an inflammatroy condition with erythematous and scaling eruptions in “seborrheic areas” (scalp, face and upper trunk)
-
who is most often affected by dandruff and SD
- Dandruff usually begins 10-20 and efefcts up to 50% of indivduals over 30
- SD is found in 1-5% of population, 30-33% of immunocompromised patietns and 83% of HIV
- Sd is most common in first 3 months of life and between 30-50
- affects more amles -> androgens affect secaceous galnd activity
development of SD
- controversy over cuase
- some say that fungal disease, others say fungal disease is secondary to the primary inflammatroy dermatosis that results in icnreased cell turnover, scalling and inflammation in epidermis
*means that treatments vary ranging from topical antifungals to topical corticosteroids and calcineuin inhibitors
*no direct relationship between amount od sebum and condiiton
*suggested response to materanl androgen stimulation
what are the goals of therapy for dandruff
Reduce or eliminate scales (dry flakes of skin) and flaking
Prevent recurrence by improving scalp hygiene
Eliminate or reduce environmental triggers
goals of therapy for seborrheic dermatitis
Control not cure
Reduce fungus and the resulting scaling and inflammation
Relieve symptoms such as pruritus
Educate on the importance of control through good hygiene
Eliminate or reduce environmental triggers
what to assess for in patients
Onset, frequency and duration of symptoms
Area and extent of involvement
Description of skin lesions
Associated systemic symptoms
Aggravating factors
Current hygiene practices
Attempted treatments
what are the symptoms of dandrugg and seborrheic dermatitis
- lesions of SD and dandrug are often asymptomatic
- variations in intensity of episodes can be precipitated by fature, stress or cold weather
- dandruff is usually asymptomatic, although itching amy develop
- in SD puritus varies, being common in scalp and ear canal involvement and can be intense
what are the sings of dandruff
- shedding of small fales from scalp showign minimal erythema with limited or no inflammation
- scales are silver-grey in patches or diffuse and may separate fully or become detached after combind
- no evidence of skin disease on scalp or elsewhere
- oftne confused with SD, tinea capitis and psoriasis
what is SD charcterized by
sharply demarcated yellow to brown, greasy or bran-like scaling patches and plaques.
- typically affects symmetic areas of skin rich in secaceous glands (hary areas of scalp, scalp margin, eyelashes, browns, beard and mustache)
- ca also affect nasolabial folds, forehead, outer ear canals and in the creases behind the ears
- can happen on torso
progression of SD
- begins in small patches, rapidly spreading, with diffuse fine scales that 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.
* can rpesent diff in indivual with dark coloured skin, appearing scaly hypopigmented macules and patches in typical areas of involvement
patterns to SD flares
resolves in a cyclic or seasonal fashion, often in response to stress.
effect of SD on eyes
- profuse powdery scales on eyeborwns and compromize wearing of contact lenses
- eyelides alone can be affected, developing blepharitis
paranasla involement of SD
typically seen in young women who may not have dandruff.
most common type fo facial SD in males
upper lip, beard, scalp, back, flanks and abdomen.
Plaques may present with thick, adherent silvery scales (as seen with psoriasis), which usually spare the face, called sebopsoriasis.
SD in infants
entire scalp may be covered with thick, dry adherent, yellowish brown scalres overlying erythema
- called ‘cradle cap”
- can also invovle central face, forehard and ears
*self limting, appears in first to fourth week fo life and usually disappears in 3 months
diagnosing SD
must be distinguished from dandruff and psoriasis
as well as tinea capitis, atopic dermatitis, rosacea, systemic lupus erythematosus and fungal skin infections.
*refer when diagnosis is uncertain or failure to respond to first line treatment after 4 weeks
what factors aggredate SD
- gnertic predisposion
- HIV positing or AIDS
- neurologi condition like parkinsons
being middle aged or elderly
- cold dry weather
- infection stress, sleep deprevation, sweat, emotional stress
- comorbid condition like pityriasis versicolor, psychiatric disorders, lcoholic pancreatitis or hepatitis C or hyperandrogen syndromes in females
what drugs are knwon to cause SD
diagnosing dadruff vs SD
- dandruff = Dry, white scales scattered diffusely over scalp
SD: Greasy, yellowish scales on face parts and scalp or eddish-brown fine scaling patches on trunk and body folds
compare features of dandrugg, SD and psoriasis
lesions
common sites
- lesions
- Dandruff: fine diffuse scales
- SD: erythema with mild greasy yellow scales, plauqes w/ indistinct margins
- Psoriasis: anular silvery scaly plaques w/ erythematous base, bleed easy
- common sites
- Dandruff: scalp
- SD: scalp: cntral face, mid chest
- Psoriasis: scalp, eblows, knees, sacrum
compare features of dandruff Sd and psoriasis
palms/soles/nails
intertrigo (skin fold involvement)
Pruritis
assosiated systemic symp
- palms/soles/nails
- Dandruff: no
- SD: no
- Psoriasis: common
- intertrigo (skin fold involvement)
- Dandruff: no
- SD: inverse type, plans penis, mostly infants
- Psoriasis: common
- Pruritis
- Dandruff: due to dryness
- SD: varie, more common if scalp/ ear canal involed
- Psoriasis: sometimes
- assosiated systemic symp
- Dandruff: none
- SD: infants or HIV patients
- Psoriasis: may gneralaize, psoriatic arthritis
describe infantile seborrhiec dermatitis
- benign and self-limiting, a conservative approach should be taken
- managment can include freq cleaning with mild non medicated shamoo and gentle brushing of scalp with soft breush
- addition of topical products to brushing to help facilitate scale removal, if desired
non pharm measures for Dandruff and SD
- disc aggregative facors
- avoid irritaing sopa,s heavy gels, hairsprays and greasy creams
- keep hair short and heard trimmed
- avoid use of excessively hot water as it may dry out the skin
- use of a cool air humidifer or dish of water to add mositure to indoor env
- exposure of affected area to sunlight and warm weather
- trat affected eyelids with warm compress, and genlte washing
- use non medicated shampoos, freq shampooing is key to control symptolms
shampoo considerations for dandrugg and SD
- freq shampooing (at least 3 times weekly) is key to controlling symptoms
- longer period of lathering may also be helpful in the case of dandruf
- Shampoos with surfactants (e.g., sodium lauryl sulfate) and detergents are better able to remove scales
- Patients who develop itching may decrease shampooing due to the drying effect but can lead to further scale accumulation
what classes of medications are used to treat dandruff and SD
antifungal agents, anti-inflammatory agents and keratolytics.
- Moisturizers play an ancillary role for softening of scale
*use topical therapy first, oral treatment for more severe cases or if ivnolves multipel body areas
ciclopirox olamine for
Dandruff and Seborrheic Dermatitis treatment
aka Loprox (cream, lotion), Stieprox (shampoo)
- Dosage
- use shampoo 2-3x weekly or as foten as req
- rub lotion into affected area BID (can apply to beard, face and body)
- Onset
- req 2-3 weeks to see onset and 4 week for pull effect
- Adverse
- pruritis, burning
- Comments
- alternative to ketoconazole
- is atient already on corticosteroid cont that for 2-3 week while waiting for antifungal to take affect, then withdraw
ketoconazole for treatment of dandruff and SD
*antifungal
- Dosage
- shampoo 2-4 times weekly
- cream: rub into aa 1d, cna aply to beard,f ace and body
- prophylaxis/maintenance treatment every 1-2 week
- Onset
- req 23 weeks to see effect, full effect @ w4
- Adverse
- <1% systemic abs
- minimal irritation, tiching tinging
- may cause greasy or dry hair
- Comments
- FIRST LIEN TREATMENT
- if on corticosteroids take those for 2-3 week while waiting for antifungal to take effect then withdraw
what if the first line treatment for dardruff and SD
- Ketoconazole
selenium sulfide for dandruff and SD
antifungal
- Dosage
- shampoo 1% or ltoion 2.5%: 2 app/week fof 2 wk then taper down
- do not use more than 3x/week
- Onset
- req 2-4 weeks
- Adverse
- excessive use >2x weekly can cause oily ahir and hair loss
- will sting if applied to broken skin
- can discolour bleached, tinted or permed ahir
- COmments
- second line therapy
- cannot use on dmaged skin
- avoi eye area
Zinc pyrithione for dandruff SD treatment
aka Head and Shoulders Shampoo, Z-Plus Shampoo, others
- Dosage
- shampoo: use 2-3x week or as often as req
- Onset
- req 2-4 weeks to see effect
- Adverse
- may discolor hiar if metal based tins are used
- safe after perm solutions
- Comments
- second line therapy
pimecrolimus (Elidel)
* Calcineurin inhibitors, topical
- Dose
- body: BID
- maintenace: 1d or 2d/week
- Onset
- req 2-4 weeks to see effect
- meed to maintain to keep condition under contorl
- Advese
- mild and transier skin burning at onset
- lacks long term seide effects fo topical corticosteroids
tacrolimus Protopic
* Calcineurin inhibitors, topical
- Dose
- thin layer aa BID
- maintenance: 1d 2 days/week
- Onset
- 2-4 weeks to see effect, need to maintain use to keep udner control
- Adverse
- Mild and transient skin burning at onset
- lacks long term side efects of topical corticosteroids
hydrocortisone
*topical corticosteroid -> not formualted for scalp
- dose
- aa BID-TID
- Onset
- 1-2 weeks, reasses after 2 weeks and cont intermittendly if needed
- Adverse
- well tol
- comments
- useful for suppressing initla inflammation
betamethasone valerate lotion
* Corticosteroids, topical (formulated for scalp)
- dose:
- app thin film BID to TID
- Onset:
- treat 1-2 weeks to see efect, reasses after 2 weeks and cont intermittently if needed
- adverse
- burning/irritation at aplication site, pruritus, dryness, atrophy
- COmments
- moderate poency topical corticosteroid
- Severe and thick scales on the scalp can respond to overnight application of topical
betamethasone valerate/salicylic acid
* Corticosteroid, topical/keratolytic combination (formulated for scalp)
- Dose
- app thin film 1d-BID to scalp
- Onset
- 1-2 weeks reasses after 2 weeks
- Adverse:
- corticosteroid can cause burning, itching, irritation, acneiform eruptions, skin atrophy, striae.
- keratolyic: erythema, scaling, local irritation.
- comments:
- mod potency topicla corticosteroids. severe thick scalon on scalp can respond overnight
coal tar
*Keratolytic agents
- doseing
- ap 1d
- onset: 2-4 weeks
- Adverse
- folliculitis, acne, contact derm, photosyn a fuck ton
- Comments
- second line treatment
salicylic acid
Keratolytic agents
- Dose
- Scalp: up to twice weekly
- Onset
- 2-4 weeks
- adverse
- irritation, redness and peeling
- irritating to mucus membranes and eyes
- younger children at higher side efect risk
- comemnts
- SA enhances penetration of topical agents though stratum corneum
sulfur
Keratolytic agents
- dose
- apply twice weekly
- onset
- 2-4 weeks
- adverse
- irritation, redness and peeling
- irritaiton to muscus membranes
- children at higer rick os unwated side eff
- comments
- in many commerical products
what atnifungals are available for SD/ dandruff
- Ketoconazole (first line, Long-term safety is favourable with chronic use, and efficacy is maintained)
- clotrimazole and miconzaole also effctive but keto prefererd
- cicloprioz olamine
selenium sulfide (use when 1st line not effective)
- Zinc pyrithione (use if more severe, not first line)
when to sue Topical calcineurin inhibitors
these are immunomodualtors
used for SD when topical corticosteroids ar enot tolerated or inapproprait e9liek when on eye lids)
ex: Tacrolimus an pimecrolimus
topical corticosteroids
- hydrocortisone 1%
- effective for dec the symp of SD, reduce pruritus and inflammation
- onyl for temproary use
Keratolytic Agents
helps detach flakes and increase penetration of other topical medications, which can improve their effectiveness.
- can be added into other topical therapy if theri repsonse was inadequate
ex: Salicylic acid, sulfur, and coal tar
NHP for dandruff and SD
Quassia amara gel: not bad efficaiy after 4 weeks
Tea tree oil: 5%effective and well tolerated in the treatment of dandruff[72] and facial SD.
aloe vera: 30 % emulsion applied twice daily improved facial SD with no significant adverse effects reported
Solanum chrysotrichum:
what parameters to monitor
slcaes
thickless of plauqe
redness
surface area involved
extension to other sites or generalization
itch/scratching
distruption of dleep/daily activites
stress/anxiety/derpession
progression of severity
recurrent episodes
