DO THE ANTI-DANDRUFF SHAMPOOS WORK?
Dr. Pamela Rojas G., Family Physician PUC
Seborrheic dermatitis is a papulo-squamous lesion that involves fat-rich areas on the scalp, face, and trunk. Its etiology has been associated with the presence of Malassezia Furfur, for which many treatments pursue its eradication (1).
Seborrheic dermatitis is a chronic condition that can appear from the month of life and is exacerbated at puberty and tends to improve after years (1, 2). It is aggravated by environmental and seasonal changes, local trauma and emotional stress (1).
The prevalence of seborrheic dermatitis is 3-5% and mainly affects men (1, 3). Dandruff, however, which is the mildest manifestation in the picture, affects 15-20% of the population (1).
The most commonly affected areas are, in order of frequency; the scalp, face, (eyebrows, nasolabial fold, sideburns) and ears (3).
Clinical manifestations are varied, ranging from scaling, in mild cases, to the formation of thick, adherent scabs (1). Among the most frequent manifestations are (3):
- Scaling of the scalp (dandruff)
- Eczematous plaques on the face, in the locations described, itchy
- Itching and inflammation of the ear canal
- Blepharitis
The following article will focus on the treatment of seborrheic dermatitis of the scalp, given the high rate of consultations that this motivates.
Indications for the management of this condition are:
General measures and symptomatic management:
a. Removal of thick crusts and reduction of the amount of fat in the skin (3):
- Skin washing should be more frequent than healthy skin.
- The scabs can be removed, moistening them. In more severe cases it is recommended to associate a keratolytic (3) (to be reviewed later).
b. Emollients: There is no CKD that compares the effectiveness of emollients in the management of adult seborrheic dermatitis (4).
2. Limit fungus development: It is recommended to wash the scalp with:
a. Shampoo of Ketoconazole (4):
b. Shampoo with Selenium Sulfide:
c. Shampoo with coal tar:
3. Associated in more severe cases:
a. Topical corticosteroids:
b. Keratolytics:
SOURCES OF INFORMATION
1. Selden S. Seborrheic dermatitis. www.emedicine.com. September 23, 2005
2. Fonseca D. Dermatitis Seborreica. Guías Clínicas Fisterra 2001; 1 (26).
3. The National Guideline Clearinghouse. Seborrhoeic dermatitis. 2004 Apr 23
4. Gee B. Seborrhoeic dermatitis. Clinical evidence, November 2003
5. Green CA, Farr PM, Shuster S. Treatment of seborrhoeic dermatitis with ketoconazole: II. Response of seborrhoeic dermatitis of the face, scalp and trunk to topical ketoconazole. Br J Dermatol 1987;116:217-221
6. Carr MM, Pryce DM, Ive FA. Treatment of seborrhoeic dermatitis with ketoconazole: I. Response of seborrhoeic dermatitis of the scalp to topical ketoconazole. Br J Dermatol 1987;116:213-216
7. Berger R, Mills OH. Double blind placebo-controlled trial of ketoconazole 2% shampoo in the treatment of moderate to severe dandruff. Adv Ther 1990;7:247-255
8. Danby FW, Maddin WS, Margesson LJ. A randomised, double-blind, placebo-controlled trial of ketoconazole 2% shampoo versus selenium sulfide 2.5% shampoo in the treatment of moderate to severe dandruff. J Am Acad Dermatol 1993;29:1008-1012.
9. Davies DB, Boorman GC, Shuttleworth D. Comparative efficacy of shampoos containing coal tar (4.0% w/w; TarmedTM), coal tar (4.0% w/w) plus ciclopirox olamine (1.0% w/w; TarmedTM AF) and ketoconazole (2.0% w/w; Nizoral®) for the treatment of dandruff/seborrhoeic dermatitis. J Dermatol Treat 1999;10:177-183
Seborrheic dermatitis is a papulo-squamous lesion that involves fat-rich areas on the scalp, face, and trunk. Its etiology has been associated with the presence of Malassezia Furfur, for which many treatments pursue its eradication (1).
Seborrheic dermatitis is a chronic condition that can appear from the month of life and is exacerbated at puberty and tends to improve after years (1, 2). It is aggravated by environmental and seasonal changes, local trauma and emotional stress (1).
The prevalence of seborrheic dermatitis is 3-5% and mainly affects men (1, 3). Dandruff, however, which is the mildest manifestation in the picture, affects 15-20% of the population (1).
Seborrheic dermatitis Symptoms
Seborrheic dermatitis is an intermittent condition in which active periods of burning, scaling, and itching alternate with inactive phases of the disease (1).The most commonly affected areas are, in order of frequency; the scalp, face, (eyebrows, nasolabial fold, sideburns) and ears (3).
Clinical manifestations are varied, ranging from scaling, in mild cases, to the formation of thick, adherent scabs (1). Among the most frequent manifestations are (3):
- Scaling of the scalp (dandruff)
- Eczematous plaques on the face, in the locations described, itchy
- Itching and inflammation of the ear canal
- Blepharitis
The following article will focus on the treatment of seborrheic dermatitis of the scalp, given the high rate of consultations that this motivates.
Seborrheic dermatitis Treatment.
It is important to inform the patient that the treatments do not provide a definitive cure for seborrheic dermatitis of the scalp (3). These patients require prolonged and repeated treatments for each outbreak (2).Indications for the management of this condition are:
General measures and symptomatic management:
a. Removal of thick crusts and reduction of the amount of fat in the skin (3):
- Skin washing should be more frequent than healthy skin.
- The scabs can be removed, moistening them. In more severe cases it is recommended to associate a keratolytic (3) (to be reviewed later).
b. Emollients: There is no CKD that compares the effectiveness of emollients in the management of adult seborrheic dermatitis (4).
2. Limit fungus development: It is recommended to wash the scalp with:
a. Shampoo of Ketoconazole (4):
- Use: apply every 2 to 3 days for 4 weeks, in 2% concentrations. Leave on for 10 minutes before rinsing (2).
- Effectiveness: 5 randomized controlled studies (RCTs) showed a significant reduction in scalp desquamation, itching and irritation in patients treated with Ketoconazole shampoo v/s placebo (5, 6, 7, 8, 9).
- Adverse effects and precautions: no significant adverse effects have been reported (4). Not approved for use in pregnant women (1)
b. Shampoo with Selenium Sulfide:
- Use: apply on scalp in concentrations at 2.5% (1, 2)
- Effectiveness: A CRT showed that its use is significantly better than placebo in reducing dandruff (66.7% with selenium v/s 44.5% with placebo) (8).
- Adverse effects: Not significant. Only a few minor local reactions (burning, itching, etc.) have been reported (8).
c. Shampoo with coal tar:
- Use: apply on scalp in concentrations at 2-3%, 2 to 3 times per week (2, 4).
- Effectiveness: An ERC showed that its use is significantly better than placebo in reducing dandruff and scalp irritation (9).
- Adverse effects: No major adverse effects have been reported (9).
3. Associated in more severe cases:
a. Topical corticosteroids:
- Use: Used as short cures to reduce symptoms. The recommendation is to begin treatment with low-potency corticosteroids (e.g., hydrocortisone), 1 to 2 times daily for one week (2).
- Effectiveness: There are no CKD comparing its use versus placebo. There is consensus among dermatologists that the use of topical corticosteroids is effective in the management of seborrheic dermatitis of the scalp (4).
b. Keratolytics:
- Use: used in conjunction with other treatments. The most commonly used is salicylic acid (2). It acts by peeling the stratum corneum of the skin.
- Effectiveness: Improvement is observed from 1 to 2 weeks of treatment. The maximum result is reached at 4 to 6 weeks (1).
Conclusion:
- Adult seborrheic dermatitis is a chronic condition requiring prolonged treatment.
- The most frequent clinical manifestation is scalp involvement.
- There are different therapeutic options available, most of which can be implemented in primary care.
- These treatments must be repeated each time the patient suffers a reactivation of his or her condition.
SOURCES OF INFORMATION
1. Selden S. Seborrheic dermatitis. www.emedicine.com. September 23, 2005
2. Fonseca D. Dermatitis Seborreica. Guías Clínicas Fisterra 2001; 1 (26).
3. The National Guideline Clearinghouse. Seborrhoeic dermatitis. 2004 Apr 23
4. Gee B. Seborrhoeic dermatitis. Clinical evidence, November 2003
5. Green CA, Farr PM, Shuster S. Treatment of seborrhoeic dermatitis with ketoconazole: II. Response of seborrhoeic dermatitis of the face, scalp and trunk to topical ketoconazole. Br J Dermatol 1987;116:217-221
6. Carr MM, Pryce DM, Ive FA. Treatment of seborrhoeic dermatitis with ketoconazole: I. Response of seborrhoeic dermatitis of the scalp to topical ketoconazole. Br J Dermatol 1987;116:213-216
7. Berger R, Mills OH. Double blind placebo-controlled trial of ketoconazole 2% shampoo in the treatment of moderate to severe dandruff. Adv Ther 1990;7:247-255
8. Danby FW, Maddin WS, Margesson LJ. A randomised, double-blind, placebo-controlled trial of ketoconazole 2% shampoo versus selenium sulfide 2.5% shampoo in the treatment of moderate to severe dandruff. J Am Acad Dermatol 1993;29:1008-1012.
9. Davies DB, Boorman GC, Shuttleworth D. Comparative efficacy of shampoos containing coal tar (4.0% w/w; TarmedTM), coal tar (4.0% w/w) plus ciclopirox olamine (1.0% w/w; TarmedTM AF) and ketoconazole (2.0% w/w; Nizoral®) for the treatment of dandruff/seborrhoeic dermatitis. J Dermatol Treat 1999;10:177-183
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