Journal of General - Procedural Dermatology & Venereology

Indonesia

Volume 5 Article 3
Issue 1 (December 2020 Edition)

12-31-2020

The management of seborrheic dermatitis 2020

Sandra Widaty
Department of Dermatology and Venereology, Faculty of Medicine Universitas Indonesia, Dr. Cipto
Mangunkusumo National General Hospital, Jakarta, Indonesia

Kusmarinah Bramono
Department of Dermatology and Venereology, Faculty of Medicine Universitas Indonesia, Dr. Cipto
Mangunkusumo National General Hospital, Jakarta, Indonesia

Muhammad Yulianto Listiawan

Department of Dermatology and Venereology, Faculty of Medicine Universitas Airlangga, Dr. Soetomo
General Hospital, Surabaya, Indonesia

See next page for additional authors

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Recommended Citation
Widaty, Sandra; Bramono, Kusmarinah; Listiawan, Muhammad Yulianto; Yosi, Ariyati; Miranda, Eliza;
Rahmayunita, Githa; Brahmanti, Herwinda; and Lim, Henry W. (2020) "The management of seborrheic
dermatitis 2020," Journal of General - Procedural Dermatology & Venereology Indonesia: Vol. 5: Iss. 1,
Article 3.
DOI: 10.19100/jdvi.v5i1.234
Available at: https://scholarhub.ui.ac.id/jdvi/vol5/iss1/3

This Article is brought to you for free and open access by the Faculty of Medicine at UI Scholars Hub. It has been
accepted for inclusion in Journal of General - Procedural Dermatology & Venereology Indonesia by an authorized
editor of UI Scholars Hub.
The management of seborrheic dermatitis 2020

Authors
• Sandra Widaty
Department of Dermatology and Venereology, Faculty of Medicine Universitas Indonesia, Dr. Cipto
Mangunkusumo National General Hospital, Jakarta, Indonesia
• Kusmarinah Bramono
Department of Dermatology and Venereology, Faculty of Medicine Universitas Indonesia, Dr. Cipto
Mangunkusumo National General Hospital, Jakarta, Indonesia
• Muhammad Yulianto Listiawan
Department of Dermatology and Venereology, Faculty of Medicine Universitas Airlangga, Dr.
Soetomo General Hospital, Surabaya, Indonesia
• Ariyati Yosi
Department of Dermatology and Venereology, Faculty of Medicine Universitas Sumatera Utara, H.
Adam Malik General Hospital, Medan, Indonesia
• Eliza Miranda
Department of Dermatology and Venereology, Faculty of Medicine Universitas Indonesia, Dr. Cipto
Mangunkusumo National General Hospital, Jakarta, Indonesia
• Githa Rahmayunita
Department of Dermatology and Venereology, Faculty of Medicine Universitas Indonesia, Dr. Cipto
Mangunkusumo National General Hospital, Jakarta, Indonesia
• Herwinda Brahmanti
Department of Dermatology and Venereology, Faculty of Medicine Universitas Brawijaya, Dr. Saiful
Anwar General Hospital, Malang, Indonesia
• Henry W. Lim
Department of Dermatology, Henry Ford Hospital, Detroit, Michigan, USA

This article is available in Journal of General - Procedural Dermatology & Venereology Indonesia:
https://scholarhub.ui.ac.id/jdvi/vol5/iss1/3
Review Article

The management of seborrheic dermatitis 2020: An update

Sandra Widaty1, Kusmarinah Bramono1, Muhammad Yulianto Listiawan2, Ariyati Yosi3,

Eliza Miranda1, Githa Rahmayunita1, Herwinda Brahmanti4, Henry W Lim5
1
Department of Dermatology and Venereology, Faculty of Medicine Universitas Indonesia,
Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
2
Department of Dermatology and Venereology, Faculty of Medicine Universitas Airlangga,
Dr. Soetomo General Hospital, Surabaya, Indonesia
3
Department of Dermatology and Venereology, Faculty of Medicine Universitas Sumatera Utara,
H. Adam Malik General Hospital, Medan, Indonesia
4
Department of Dermatology and Venereology, Faculty of Medicine Universitas Brawijaya,
Dr. Saiful Anwar General Hospital, Malang, Indonesia
5
Department of Dermatology, Henry Ford Hospital, Detroit, Michigan, USA

Email: [email protected]

Abstract

Background: Seborrheic dermatitis (SD) is a chronic relapsing dermatitis manifesting in the seborrheic area,
affecting infants or adults. In Indonesia, the prevalence of SD is 0.99–5.8% of all dermatology cases from 2013
to 2015. SD has been known to be a prominent manifestation among HIV patients, but there is an increasing
trend in the general population. Therefore, in 2017, the Indonesian Society for Dermatology and Venereology
proposed a consensus for the management of SD in Indonesia based on the discussion from 12 dermatological
centers. Concurrent with the development of new drugs, this study aims to evaluate and develop a guideline
for the treatment of seborrheic dermatitis in Indonesia to update the previous guidelines in 2017.
Methods: Systematic review was based on evidence-based methods, and scientific evidences were acquired
through systematic search. Evidence analysis was in accordance with the level of evidence. The available
evidences were evaluated, and conclusion was based on the grade of recommendation. Critical appraisal was
conducted by experts in dermatology and venereology.
Results: Severity of SD can be determined by using the Seborrheic Dermatitis Area Severity Index. The
principle of scalp SD management is controlling the scalp condition in a cost-effective manner to make patients
comfortable. The recommendations for treatment of adult SD are topical agents, such as antifungals,
nonsteroidal anti-inflammatory agents with antifungal properties, corticosteroids, and calcineurin inhibitors.
Conclusion: We have updated and added newer agents for the treatment of SD. The approach is divided into
scalp or nonscalp and also adult or infantile SD.

Keywords: seborrheic dermatitis, management approach, diagnosis, Seborrheic Dermatitis Area Severity
Index, guidelines

Background In Indonesia, the prevalence of SD is 0.99–5.8% of

all dermatology cases in 2013–2015. On the other
Seborrheic dermatitis (SD) is a chronic relapsing hand, the prevalence of human immunodeficiency
dermatitis manifesting in the seborrheic area. The virus (HIV) infection keeps increasing in Indonesia,
clinical manifestations range from poorly defined resulting in an increase in the overall prevalence of
erythematous patch to plaque with flaky white or SD and more recalcitrant cases. 1
yellow scales. SD can occur in infants or adults with
male predominance in the third to fourth decade of The management of SD is targeted to reduce or
life.1 diminish clinical signs and symptoms, mainly scale
and pruritus, and also to maintain remission.1

J Gen Proced Dermatol Venereol Indones. 2020:5(1);19-27 19

Cheong et al. have developed a guideline for the Results
treatment of SD in the Asian population. Initial
treatment for SD can be performed by general Assessment of SD severity
practitioners, dermatologists, or a collaboration of The severity of SD can be determined using
both since mild SD can be treated by the former. 2 Seborrheic Dermatitis Area Severity Index
(SDASI), as shown below.1
In 2017, the Indonesian Society for Dermatology • Determination of the local area score on each
and Venereology had published a National Clinical area, which is the percentage of SD symptom
Practice Guideline for the Treatment of SD in on the affected area compared to the
Indonesia. We proposed an update for this surrounding area
guideline due to the increasing incidence of SD and 1: ≤10%
availability of medications in Indonesia.1 2: 11%–30%
3: 31%–50%
Methods 4: 51%–70%
5: >70%
This review was based on the data of a 2016–2017 • Assessment of the degree of erythema (E),
systematic review1 and an additional review from papules (P), and scales (S) on each area:
July 2019 to December 2019. Literature review was 0: None
conducted based on the principle of evidence- 1: Mild
based methods, and scientific evidences were 2: Moderate
acquired through systematic search. Three 3: Severe
databases were used: Cochrane Library, Google • Calculation of SDASI score of each area
Scholar, and PubMed. The keywords used were (E+P+S) × Local Area Score
seborrheic dermatitis, seborrheic eczema, • Quantification of all three SDASI scores
outcome measures, quality of life, management, • Classification of SD severity according to the
and therapy. SDASI score
Mild : 0–7.9
The level of evidence (LoE) is determined based
Moderate : 8–15.9
on the classification developed by Oxford Centre
Severe : >16
for Evidence-Based Medicine (Table 1).3 In this
study, modifications were made if no high-level
evidence was noted. Based on the LoE, the
recommendation can be made (Table 2).4

Table 1. Level of evidence based on Oxford Centre for Evidence-Based Medicine4

Level Description
1 Meta-analysis or systematic review of randomized controlled trials (RCTs)
Individual RCT
2 Nonsystematic review of RCTs
Systematic review of cohort studies
Individual cohort study
3 Non-RCT study
Systematic review of case-control studies
Individual case-control study
4 Serial cases and cohort study and case-control study with low validation
5 Expert’s opinion without well-defined critical appraisal or only based on physiology

Table 2. Grade of Recommendation Based on Level of Evidence (LoE)4

Grade Definition LoE

A Very recommended to be applied Level 1
B Recommended to be applied Level 2, 3 or extrapolation of level 1
C Can be applied Level 4 or extrapolation of level 2, 3
D Not recommended to be applied Level 5 or other studies not included in levels 1–4

J Gen Proced Dermatol Venereol Indones. 2020:5(1);19-27 20

Management
The principle of scalp SD management is Indonesia has implemented several policies
controlling the scalp condition in a cost-effective regarding management of diseases in primary care
manner to make patients comfortable. The facilities. Mild SD without comorbidities can be
medication for SD should be accepted treated in primary care, while moderate-to-severe
aesthetically, meaning it can be used with daily hair SD with and without comorbidities are referred to
care products, which leads to an increase of as secondary or tertiary care facilities. Therefore,
compliance and successful management. Several we developed an algorithm for mild and moderate-
factors considered prior to determining treatment to-severe SD. Different agents were used for scalp
for SD are age, comorbidities, the potency of and nonscalp SD. Figures 1 and 2 show algorithms
agents, efficacy of topical agents, comfortability for the management of SD. Tables 3, 4 and 5, on
and compliance, and drug’s safety. Patients should the other hand, show the recommendations for
also be advised to avoid predisposing factors (use management.1
of air conditioner, low humidity, scratching, irritating
agents, high-fat food).1

Figure 1. Algorithm for the Management of Adult Seborrheic Dermatitis (SD) in the Nonscalp Area Based on
Severity.1 NSAID: nonsteroidal anti-inflammatory drug
cited with modifications from reference 1

J Gen Proced Dermatol Venereol Indones. 2020:5(1);19-27 21

Figure 2. Algorithm for the Management of Adult Seborrheic Dermatitis (SD) in Scalp and Nonglabrous Skin
Based on Severity.1 NSAID: nonsteroidal anti-inflammatory drug

Table 3. Management of Nonscalp Seborrheic Dermatitis 1

Product Formula Dosage LoE GoR

Mild SD
Topical antifungal agents Ketoconazole cream 2% Twice a day for 4 weeks 1 A
Terbinafine cream 1 A
AIAFp (nonsteroidal anti- Piroctone olamine/algycera or 1 A
inflammatory agent with bisabolol cream
antifungal properties)
Topical corticosteroid Hydrocortisone 1% cream and 1 A
ointment
Topical calcineurin inhibitor Pimecrolimus 1% cream 1 A
Tacrolimus 0.1% ointment 1 A
Moderate-to-severe SD
Topical corticosteroid (class Aclometasone 0.05% Twice a day for 4 weeks 1 A
2) ointment*
Desonide 0.05% cream 1 A
Systemic antifungal agents Itraconazole 100 mg capsule First month: 200 mg/day for 1 week 1 A
continued with 2 days/month until
11 months
Terbinafine 250 mg capsule Continuous regiment: 250 mg/day 1 A
for 4-6 weeks
Intermittent regimen: 250 mg/day
for 12 days per month for 3 months
Fluconazole 50 mg capsule 50 mg/day for 2 weeks or 200-300 1 A
mg/week for 2-4 weeks
Others Phototherapy Narrowband ultraviolet B 3 times a 4 C
week for 8 weeks
GoR: grade of recommendation, LoE: level of evidence, SD: seborrheic dermatitis, *not available in Indonesia,
cited with modifications from reference 1

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Table 4. Management of Scalp Seborrheic Dermatitis1

Medication Preparation Dosage LoE GoR

Mild SD
Topical antifungal agents Ketoconazole 1%–2% shampoo 2–3 times a week 1 A
AIAFp (nonsteroidal anti- Piroctone 2–3 times a week 1 A
inflammatory agent with olamine/bisabolol/glycyrrhetinic
antifungal properties) acid/lactoferrin shampoo
Keratolytic and tar Preparation containing salicylic acid Salicylic acid shampoo 1–3 1 A
3%, tar 1%–2% and combination times a week
Other agents Selenium sulfide 2.5% shampoo 2–3 times a week 1 A
Zinc pyrithione 1%–2% shampoo
Topical corticosteroid
Class I Hydrocortisone 1% cream Once a day for 4 weeks 1 A
Class II Aclometasone 0.05% ointment 1 A
Desonide 0.05% cream
Moderate-to-severe SD
Topical corticosteroid
Class I Hydrocortisone 1% cream Once a day for 4 weeks 1 A
Class II Aclometasone 0.05% ointment 1 A
Desonide 0.05% cream
Topical corticosteroid
Class III Mometasone 0.1% solution or cream Once a day for 4 weeks 1 A
Class IV Clobetasol propionate 0.05% Twice a week, leave on for 5 1 A
shampoo minutes, for 2 weeks
Systemic antifungal agents Itraconazole capsule 100 mg First month: 200 mg/day for 1 1 A
week, followed by 2
days/month for 11 months
Terbinafine capsule 250 mg Continuous regiment: 250 1 A
mg/day for 4–6 weeks
Fluconazole capsule 50 mg 50 mg/day for 2 weeks or 200– 1 A
300 mg/week for 2–4 weeks
GoR: grade of recommendation, LoE: level of evidence, SD: seborrheic dermatitis

Table 5. Management of Infantile Seborrheic Dermatitis1

Medication Preparation Dosage Notes LoE GoR

Scalp and hairy area
Topical antifungal Ketoconazole 2% shampoo Twice a week A study in 13 patients 1 A
agents for 4 weeks (<1-year-old) showed
no systemic absorption
or liver function disorder
after 11-month use
Emollient White petrolatum ointment Daily use Softens the scales to 1 A
ease manual release
AIAFp Piroctone Every 12 hours Effective for cradle cap 1 A
olamine/alglycera/bisabolol cream
Nonscalp area
Topical antifungal Ketoconazole 2% cream Once a day for Can be used alone or in 1 A
agents 7 days combination with topical
corticosteroid
Topical Hydrocortisone 1% cream Once a day for Limited area 1 A
corticosteroid 7 days
(class I)
GoR: grade of recommendation, LoE: level of evidence, SD: seborrheic dermatitis

Antifungal agents agents. Each drug has a specific site of action that
The development of antifungal agents is not as causes the efficacy, duration of treatment, and
progressive as the development of antibacterial adverse effect to differ from one another.5

J Gen Proced Dermatol Venereol Indones 2020:5(1);19-27 23

Systemic antifungal agents or inhibiting this enzyme can disrupt the
Systemic antifungal agent is the treatment of clearance of allylamines. Other interactions are
choice for deep mycosis (subcutaneous mycosis also reported with the use of cyclosporine,
and systemic mycosis) and some superficial warfarin, and drugs metabolized by CYP2D6.
mycoses. The choice of agents is determined by Terbinafine is a systemic allylamine. 5
several considerations, such type of fungi, cure
rate, cost-benefit analysis, adverse effect, drug c. Terbinafine
interaction, comfortability, age, general condition, Terbinafine is absorbed in the gastrointestinal
and patient’s medical history. Several things that tract. The preparations are in the forms of tablet
can cause drug interaction, adverse effect due to and granules. It is lipophilic and keratophilic, so
insufficient organ function, and teratogenic adverse it is widely distributed in the skin, nail, and fat.
effect should be taken into account prior to drug The bioavailability of terbinafine is 40%, with a
administration.5 half-life of 22 hours. Metabolism occurs in the
liver through oxidation by CYP2D6. Elimination
a. Azoles occurs mainly through urine (80%) and feces.
Azoles are classified into imidazole and triazole Rifampin increases the clearance of terbinafine,
based on the number of nitrogen atoms on the while cimetidine decreases the clearance of
azole chain. Ketoconazole is an example of terbinafine. Terbinafine increases plasma
imidazole, while itraconazole, fluconazole, concentration of several drugs, such as tricyclic
voriconazole, and posaconazole are examples antidepressants, beta blocker, selective
of triazole. Its mechanism of action is the serotonin reuptake inhibitor, and monoamine
inhibition of lanosterol 14α-demethylase, and oxidase type B inhibitor.5
cytochrome P450 (CYP450), leading to the
disruption of ergosterol synthesis, causing Corticosteroid
instability and hyperpermeability of the cell Topical corticosteroid with low-to-medium potency
membrane, which disrupts fungal growth and is indicated in severe SD. This agent can be used
life sustainability. The most common adverse alone or with an antifungal agent to manage the
effect is gastrointestinal disorder, whereas the inflammation, mainly erythema and pruritus.
less common adverse effects are liver function Prolonged use is not advised due to potential
disorder, cardiac toxicity, hypertriglyceridemia, adverse effects, such as hypertrichosis, skin
edema, urticaria, anaphylaxis, neuropathy, atrophy, telangiectasia, perioral dermatitis, etc.
hypertension, impotence, and leukopenia. Several studies have shown that monotherapy with
Azole interacts with CYP3A4, so the use of topical corticosteroid was not superior to topical
azole with drugs metabolized by these enzymes antifungal agent. Therefore, antifungal agents are
can cause changes in both drugs’ plasma still considered first-line treatment for mild SD, but
concentrations. Absorption of azole is also topical corticosteroids are the first-line treatment
disrupted if being consumed with antacid, H2 for moderate-to-severe SD.6
blocker, and proton pump inhibitor.5
Topical AIAFp (nonsteroidal anti-inflammatory
b. Allylamines agent with antifungal properties)
Allylamines’ mechanism of action is inhibition of a. Piroctone olamine
squalene epoxidase, a non-cytochrome P450 Piroctone olamine is an ethanolamine salt
enzyme, leading to the disruption of ergosterol derived from hydroxamic acid. It has antifungal
biosynthesis. This class has fungicidal and properties and can be found in cosmetic
fungistatic activities. The fungicidal activity is products with 0.5% or 1% concentration. Its
acquired through the accumulation of squalene, mechanism of action is by penetrating the cell
which weakens fungi’s cell membrane, while membrane, binding to iron ions and making
fungistatic activity is acquired through complexes, and then inhibiting the metabolism
ergosterol deficiency, which leads to the of energy in the protein mitochondria. This
disruption of membrane function in fungal agent is often combined with climbazole, an
growth. The most common adverse effect is antifungal agent that binds fungal P-450,
gastrointestinal disorder, whereas the less leading to the inhibition of P-450-mediated
common adverse effects are headache, effects. Several studies on the application of
exanthematous eruption, pustular psoriasis, climbazole/piroctone olamine cream and
chest pain, malaise, fatigue, liver disorder, and shampoo showed effectiveness in reducing
toxic epidermal necrolysis. This class is erythema and sebum on the face and scalp. 7
metabolized by CYP450, so the drugs inducting

J Gen Proced Dermatol Venereol Indones 2020:5(1);19-27 24

b. Bisabolol are rarely associated with adverse effects.
Bisabolol is a monocyclic sesquiterpene alcohol However, prolonged use is not advised due to a
with antioxidant and anti-inflammatory report of malignancy in patients using topical
properties. Its mechanism of action is by calcineurin inhibitors for long-term use. Several
downregulating polymorphonuclear neutrophil studies comparing pimecrolimus cream and topical
and releasing reactive oxygen species. It is corticosteroids (betamethasone 17-valerate 0.1%
found to be protective of the gastric epithelium cream or hydrocortisone acetate 1% cream) have
from nitric oxide and prostaglandins. This effect shown that they are equally effective in SD.
is thought to be also applied on the skin due to Pimecrolimus cream was also found to
the similarities between skin and gastric demonstrate a milder relapse and longer duration
epithelia. For SD, bisabolol is shown to be of remission. For tacrolimus ointment, it was shown
effective, but it should be used in combination to have better efficacy than topical corticosteroids
with other agents, such as piroctone olamine, but was not superior to zinc pyrithione shampoo.
alglycera, and temesteine.7 The application of tacrolimus ointment is generally
not well accepted by patients due to its
c. Glycyrrhetinic acid greasiness.7,8
It originates from black licorice. It has anti-
inflammatory, anti-irritation, anti-allergy, and Tar and keratolytics
antivirus properties. The mechanism of action is a. Coal tar
by inhibiting 11-β-hyroxysteroid This agent has keratoplastic properties, which is
hydroxygenase, leading to the inhibition of useful in SD. The previous study showed that
hydrocortisone conversion in steroid the use of coal tar extract 8.75% in liquid
metabolism, exerting its anti-inflammatory detergent daily prior to shampooing and two
properties. A randomized, comparative study times per week for 3 weeks was found to
showed that a shampoo containing 18β- improve SD signs and symptoms in 86.4% of
glycyrrhetinic acid in ciclopirox olamine and zinc the subjects.7
pyrithione had significant clinical improvement,
marked by a decrease of erythema, dandruff, b. Salicylic acid/lipohydroxy acid (LHA)
and amount of Malassezia spp. on the skin LHA is found to induce stimulation of re-
surface 2 weeks post-therapy.7 epithelization and desquamation and has
antimicrobial properties against Malassezia
d. Lactoferrin ovalis. Previous study showed that the use of
Its mechanism of action is hypothesized by shampoo containing LHA 0.1% and salicylic
modulation of function, maturation, and acid 1.3% was found to reduce erythema, scale,
migration of immune cells, as well as binding pruritus, and dryness following topical
and interaction of iron with other compounds. A application every 2 days for 4 weeks.7
previous study measuring the effect of a topical
gel containing lactoferrin, ciclopirox olamine, c. K301
aloe vera, and glycerol-phosphoinositol showed K301 or Kaprolac is a mixture of lactic acid,
that it caused significant reductions of urea, propylene glycol, and a small amount of
erythema, itch, and desquamation.7 water and glycerol. It has keratolytic, hydrating,
exfoliating, and antifungal properties. Significant
e. Promiseb® clinical improvement can be seen following 2
Promiseb® is combination of lycyrrhetinic acid weeks of treatment. The possible adverse
and piroctone olamine cream with antifungal effects are erythema, rash, pruritus, burning
and anti-inflammatory properties. It has been sensation, eczema, and ulceration. 7
shown to be equally effective as desonide
cream in reducing SD signs and symptoms. It is Selenium sulfide
effective in controlling flares with less probability This topical agent has antifungal properties by
of relapse without any potential serious adverse promoting shedding of the stratum corneum in the
effects.7 infected site. Selenium sulfide 2.5% shampoo is
found to be effective in treating moderate-to-severe
dandruff, especially in the reduction of pruritus and
Topical calcineurin inhibitors (TCIs) irritation. Unfortunately, it is less tolerated than
The mechanism of action for calcineurin inhibitors ketoconazole shampoo due to its residual odor and
is by inhibiting T cell-induced cytokine secretion, hair discoloration.7
which will lead to a decrease in inflammation. TCIs

J Gen Proced Dermatol Venereol Indones 2020:5(1);19-27 25

Phototherapy 5. Nicotinamide
Ultraviolet has been shown to inhibit Malassezia Nicotinamide is a water-soluble amide, which is
growth on the skin. Ultraviolet B (UVB) can be also soluble in nicotinic acid. The mechanism of
considered for severe or recalcitrant SD. Previous action is by inhibiting sebocyte secretion and
study showed an improvement in patients treated anti-inflammatory properties with a dose-
with NB-UVB three times a week for 2 months. dependent manner. In an open-label,
However, relapse occurred in 2–6 weeks following randomized study of 48 SD patients
the discontinuation of therapy. On the other hand, administered with nicotinamide 4% cream, a
the studies of psoralen plus ultraviolet A (PUVA) 75% reduction of the total score was shown.9
are still contradictory. Not to mention, a substantial
risk of carcinogenic effects in fair-skinned 6. Propylene glycol
individuals is noted.6 It is a non-aromatic substance, acting as a
humectant with hygroscopic and absorbability
Other agents properties. It has been used as an alternative of
1. Anethum graveolens corticosteroid in the treatment of scalp SD. It
It is a plant from the Apiceae or Umbeliferae can also significantly reduce the colony of
family. Based on a randomized, double-blind Pityrosporum orbiculare.9
comparative study in 115 DS patients on facial
skin, the use of Anethum graveolens can 7. Quassia Amara
prevent recurrence. Following an 8-week use, It is a substance rich of triterpenoid quassinoids
the recurrence rate (21%) was lower in the with antimicrobial, antifungal, and anti-
control group (40%), which could be explained inflammatory properties. In a close-label,
by the regulation effects of toll-like receptor randomized, comparative study, the Quassia
(TLR).9 extract 4% gel was shown to be effective and
safe and can be tolerated for facial SD.9
2. Emu oil
Emu oil originates from emu bird’s fat tissue 8. Tea tree oil
(Dromaius novohollandiae) with antioxidant and It is originated from Melaleuca alternifolia with
anti-inflammatory properties. A randomized, antimicrobial and anti-inflammatory properties.
controlled study in 126 SD patients on facial skin A close-label, randomized study in scalp SD
showed reduction in pruritus and erythema as patients showed that this agent can exert better
much as 20%. However, its effectivity was lower clinical improvement than placebo. However,
than that of 1% clotrimazole and 1% the use of tea tree oil is limited due to the
hydrocortisone.9 possibility of estrogenic and anti-androgenic
effects.9
3. Hyaluronic acid
Hyaluronic acid is a non-sulfate anionic 9. Other natural agents
glycosaminoglycans, abundant in connective, Other natural agents, such as Allantoin, Aloe
epithelial, and nerve tissues. A prospective vera, Borrago officinalis, Arctium lappa,
study administering hyaluronic acid sodium salt Echinacea purpurea, Incense, Lactoferrin,
gel 0.2% in SD patients on facial skin twice a Potassium alum, Retinyl palmitate, salicylic
day following facial wash reported a reduction of acid, Tarassaco, and vitamin E can be used in
scales (76%), erythema (64%), and pruritus the management of SD or similar conditions
(50%).9 through their roles as moisturizers, keratolytics,
anti-inflammation, antioxidant, immunology,
4. Lithium gluconate antimicrobial, antifungal, sebum and itch
It is a monovalent cation with suspected anti- modulatory. However, the study on their
inflammatory properties. Based on a efficacies and mechanisms of action has not
multicenter, randomized study in 290 DS been conducted.
patients, the effectivity of lithium gluconate 8%
ointment (52%) was higher than ketoconazole Conclusion
2% cream (30.1%). The safety of both drugs is
similar. A randomized study showed 90.9% The principles of management in SD are
remission in the group using lithium gluconate eliminating or improving clinical signs and
8% ointment compared to the control group symptoms, maintaining remission, and avoiding
(54.7%).9 predisposing and precipitating factors. The

J Gen Proced Dermatol Venereol Indones 2020:5(1);19-27 26

recommendations for mild nonscalp adult SD are Jakarta: Central Communications; 2017. p.1-
topical agents, such as antifungals, non-steroidal 29.
anti-inflammatory drugs (NSAID) with antifungal 2. Cheong WK, Yeung CK, Torsekar RG, et al.
properties, class I corticosteroids, and calcineurin Treatment of seborrhoeic dermatitis in Asia: A
inhibitors. (LoE 1A), while the recommendations consensus guide. Skin Appendage Disord.
for moderate/severe nonscalp adult SD are class II 2016;1:187-96.
corticosteroids and systemic antifungals (LoE 1A). 3. Centers for Evidence-Based Medicine
Moreover, phototherapy may be recommended University of Oxford. Critical appraisal tools.
(LoE 4C). For mild adult scalp SD, the 2019 [Accessed on 2019 December 31].
recommendations are the same as nonscalp Available from: https://www.cebm.ox.ac.uk/
areas, with the addition of class II corticosteroids resources/ebm-tools/critical-appraisal-tools.
and other formulations with keratolytic properties, 4. Centers for Evidence-Based Medicine
or mild antifungals. (LoE 1A). For moderate/severe University of Oxford. Levels of evidence. 2019
adult scalp SD, the recommendations are the same [Accessed on 2019 December 31]. Available
as nonscalp areas, with the addition of from: https://www.cebm.ox.ac.uk/resources/
corticosteroids ranging from class I to IV (LoE 1A). levels-of-evidence.
There is no recommendation for phototherapy. The 5. Widaty S. Obat antijamur untuk mikosis
recommendations for infantile scalp SD are profunda. In: Siswati A, Adriani A, Miranda E, et
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