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American Journal of Clinical Dermatology

, Volume 5, Issue 6, pp 417–422 | Cite as

Role of Antifungal Agents in the Treatment of Seborrheic Dermatitis

  • Aditya K. GuptaEmail author
  • Karyn Nicol
  • Roma Batra
Therapy in Practice

Abstract

Seborrheic dermatitis is a superficial fungal disease of the skin, occurring in areas rich in sebaceous glands. It is thought that an association exists between Malassezia yeasts and seborrheic dermatitis. This may, in part, be due to an abnormal or inflammatory immune response to these yeasts. The azoles represent the largest class of antifungals used in the treatment of this disease to date. In addition to their antifungal properties, some azoles, including bifonazole, itraconazole, and ketoconazole, have demonstrated anti-inflammatory activity, which may be beneficial in alleviating symptoms. Other topical antifungal agents, such as the allylamines (terbinafine), benzylamines (butenafine), hydroxypyridones (ciclopirox), and immunomodulators (pimecrolimus and tacrolimus), have also been effective. In addition, recent studies have revealed that tea tree oil (Melaleuca oil), honey, and cinnamic acid have antifungal activity against Malassezia species, which may be of benefit in the treatment of seborrheic dermatitis. In cases where seborrheic dermatitis is widespread, the use of an oral therapy, such as ketoconazole, itraconazole, and terbinafine, may be preferred. Essentially, antifungal therapy reduces the number of yeasts on the skin, leading to an improvement in seborrheic dermatitis. With a wide availability of preparations, including creams, shampoos, and oral formulations, antifungal agents are safe and effective in the treatment of seborrheic dermatitis.

Keywords

Itraconazole Azole Antifungal Agent Terbinafine Lanosterol 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

No sources of funding were used to assist in the preparation of this review. The authors have no potential conflicts of interest, past funding, consultancies, honoria etc. that are directly relevant to the content of this review.

References

  1. 1.
    Burton JL. Seborrheic dermatitis. In: Wilkinson DS, Ebling FJG, editors. Textbook of dermatology. Oxford: Blackwell Scientific Publications, 1992: 1561–1622Google Scholar
  2. 2.
    Hancox JG, Sheridan SC, Feldman SR, et al. Seasonal variation of dermatologic disease in the USA: a study of office visits from 1990 to 1998. Int J Dermatol 2004; 43 (1): 6–11PubMedCrossRefGoogle Scholar
  3. 3.
    Pierard-Franchimont C, Hermanns JF, Degreef H, et al. From axioms to new insights into dandruff. Dermatology 2000; 200 (2): 93–8PubMedCrossRefGoogle Scholar
  4. 4.
    Berg M. Epidemiological studies of the influence of sunlight on the skin. Photodermatol 1989; 6: 80–4PubMedGoogle Scholar
  5. 5.
    Tegner E. Seborrhoeic dermatitis of the face induced by PUVA treatment. Acta Derm Venereol 1983; 63: 335–9PubMedGoogle Scholar
  6. 6.
    Gueho E, Midgley G, Guillot J. The genus Malassezia with description of four new species. Antonie van Leeuwenhoek 1996; 69: 337–55PubMedCrossRefGoogle Scholar
  7. 7.
    Nell A, James SA, Bond CJ, et al. Identification and distribution of a novel Malassezia species yeast on normal equine skin. Vet Rec 2002; 150: 395–8PubMedCrossRefGoogle Scholar
  8. 8.
    Sugita T, Takashima M, Shinoda T, et al. New yeast species, Malassezia dermatis, isolated from patients with atopic dermatitis. J Clin Microbiol 2002; 40: 1363–7PubMedCrossRefGoogle Scholar
  9. 9.
    Crespo EV, Delgado FV. Malassezia species in skin diseases. Curr Opin Infect Dis 2002; 15: 133–42CrossRefGoogle Scholar
  10. 10.
    Shuster S. The aetiology of dandruff and the mode of action of therapeutic agents. Br J Dermatol 1984; 111: 235–42PubMedCrossRefGoogle Scholar
  11. 11.
    Faergemann J. Management of seborrheic dermatitis and pityriasis versicolor. Am J Clin Dermatol 2000; 1: 75–80PubMedCrossRefGoogle Scholar
  12. 12.
    Watanabe S, Kano R, Sato H, et al. The effects of Malassezia yeasts on cytokine production by human keratinocytes. J Invest Dermatol 2001; 116: 769–73PubMedCrossRefGoogle Scholar
  13. 13.
    Faergemann J, Bergbrant IM, Dohse M, et al. Seborrhoeic dermatitis and Pityrosporum (Malassezia) folliculitis: characterization of inflammatory cells and mediators in the skin by immunohistochemistry. Br J Dermatol 2001; 144: 549–56PubMedCrossRefGoogle Scholar
  14. 14.
    Hay RJ, Graham-Brown RA. Dandruff and seborrhoeic dermatitis: causes and management. Clin Exp Dermatol 1997; 22: 3–6PubMedCrossRefGoogle Scholar
  15. 15.
    Pierard GE. Seborrheic dermatitis today, gone tomorrow? The link between the biocene and treatment. Dermatology 2003; 206: 187–8PubMedCrossRefGoogle Scholar
  16. 16.
    Shemer A, Nathansohn N, Kaplan B, et al. Treatment of scalp seborrheic dermatitis and psoriasis with an ointment of 40% urea and 1% bifonazole. Int J Dermatol 2000; 39: 532–4PubMedCrossRefGoogle Scholar
  17. 17.
    Segal R, David M, Ingber A, et al. Treatment with bifonazole shampoo for seborrhea and seborrheic dermatitis: a randomized, double-blind study. Acta Derm Venereol 1992; 72: 454–5PubMedGoogle Scholar
  18. 18.
    Shiri J, Amichai B. Treatment of seborrheic dermatitis of the scalp and dandruff with a shampoo containing 1% bifonazole (Agispor shampoo). J Dermatolog Treat 1998; 9: 95–6CrossRefGoogle Scholar
  19. 19.
    Zienicke H, Korting HC, Braun-Falco O, et al. Comparative efficacy and safety of bifonazole 1% cream and the corresponding base preparation in the treatment of seborrhoeic dermatitis. Mycoses 1993; 36: 325–31PubMedCrossRefGoogle Scholar
  20. 20.
    Wigger-Alberti W, Kluge K, Elsner P. Clinical effectiveness and tolerance of climbazole containing dandruff shampoo in patients with seborrheic scalp eczema [in German]. Schweiz Rundsch Med Prax 2001; 90: 1346–9Google Scholar
  21. 21.
    Go IH, Wientjens DPWM, Koster M. A double-blind trial of 1% ketoconazole shampoo versus placebo in the treatment of dandruff. Mycoses 1992; 35: 103–5PubMedCrossRefGoogle Scholar
  22. 22.
    Pierard-Franchimont C, Pierard GE, Arrese JE, et al. Effect of ketoconazole 1% and 2% shampoos on severe dandruff and seborrhoeic dermatitis: clinical, squamometric and mycological assessments. Dermatology 2001; 202: 171–6PubMedCrossRefGoogle Scholar
  23. 23.
    Peter RU, Richarz-Barthauer U. Successful treatment and prophylaxis of scalp seborrhoeic dermatitis and dandruff with 2% ketoconazole shampoo: results of a multicentre, double-blind, placebo-controlled trial. Br J Dermatol 1995; 132: 441–5PubMedCrossRefGoogle Scholar
  24. 24.
    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: 213–6PubMedCrossRefGoogle Scholar
  25. 25.
    Danby FW, Maddin WS, Margesson LJ, et al. A randomized, 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: 1008–12PubMedCrossRefGoogle Scholar
  26. 26.
    Dobrev H, Zissova L. Effect of ketoconazole 2% shampoo on scalp sebum level in patients with seborrhoeic dermatitis. Acta Derm Venereol 1997; 77: 132–4PubMedGoogle Scholar
  27. 27.
    Pierard-Franchimont C, Goffin V, Decroix J, et al. A multicenter randomized trial of ketoconazole 2% and zinc pyrithione 1% shampoos in severe dandruff and seborrheic dermatitis. Skin Pharmacol Appl Skin Physiol 2002; 15: 434–41PubMedGoogle Scholar
  28. 28.
    Shuttleworth D, Squire RA, Boorman GC, et al. Comparative clinical efficacy of shampoos containing ciclopirox olamine (1.5%) or ketoconazole (2%, Nizoralâ) for the control of dandruff/seborrhoeic dermatitis. J Dermatolog Treat 1998; 9: 157–62CrossRefGoogle Scholar
  29. 29.
    Squire RA, Goode K. A randomised, single-blind, single-centre clinical trial to evaluate comparative clinical efficacy of shampoos containing ciclopirox olamine (1.5%) and salicylic acid (3%), or ketoconazole (2%, Nizoral) for the treatment of dandruff/seborrhoeic dermatitis. J Dermatolog Treat 2002; 13: 51–60PubMedCrossRefGoogle Scholar
  30. 30.
    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: 217–21PubMedCrossRefGoogle Scholar
  31. 31.
    Katsambas A, Antoniou C, Frangouli E, et al. A double-blind trial of treatment of seborrhoeic dermatitis with 2% ketoconazole cream compared with 1% hydrocortisone cream. Br J Dermatol 1989; 121: 353–7PubMedCrossRefGoogle Scholar
  32. 32.
    Pari T, Pulimood S, Jacob M, et al. Randomised double blind controlled trial of 2% ketoconazole cream versus 0.05% clobetasol 17-butyrate cream in seborrhoeic dermatitis. J Eur Acad Dermatol Venereol 1998; 10: 89–90PubMedCrossRefGoogle Scholar
  33. 33.
    Skinner Jr RB, Noah PW, Taylor RM, et al. Double-blind treatment of seborrheic dermatitis with 2% ketoconazole cream. J Am Acad Dermatol 1985; 12: 852–6PubMedCrossRefGoogle Scholar
  34. 34.
    Stratigos J, Antoniou C, Katsambas A, et al. Ketoconazole 2% cream versus hydrocortisone 1% cream in the treatment of seborrheic dermatitis. J Am Acad Dermatol 1988; 19: 850–3PubMedCrossRefGoogle Scholar
  35. 35.
    Ortonne JP, Lacour JP, Vitetta A, et al. Comparative study of ketoconazole 2% foaming gel and betamethasone dipropionate 0.05% lotion in the treatment of seborrhoeic dermatitis in adults. Dermatology 1992; 184: 275–80PubMedCrossRefGoogle Scholar
  36. 36.
    Pierard GE, Pierard-Franchimont C, Van Cutsem J, et al. Ketoconazole 2% emulsion in the treatment of seborrheic dermatitis. Int J Dermatol 1991; 30: 806–9PubMedCrossRefGoogle Scholar
  37. 37.
    Parsad D, Pandhi R, Negi KS, et al. Topical metronidazole in seborrheic dermatitis: a double-blind study. Dermatology 2001; 202: 35–7PubMedCrossRefGoogle Scholar
  38. 38.
    Faergemann J. Seborrhoeic dermatitis and Pityrosporum orbiculare: treatment of seborrhoeic dermatitis of the scalp with miconazole-hydrocortisone (Daktacort), miconazole and hydrocortisone. Br J Dermatol 1986; 114: 695–700PubMedCrossRefGoogle Scholar
  39. 39.
    Pierard-Franchimont C, Pierard GE. A double-blind placebo-controlled study of ketoconazole + desonide gel combination in the treatment of facial seborrheic dermatitis. Dermatology 2002; 204: 344–7PubMedCrossRefGoogle Scholar
  40. 40.
    Sheth RA. A comparison of miconazole nitrate and selenium disulfide as anti-dandruff agents. Int J Dermatol 1983; 22: 123–5PubMedCrossRefGoogle Scholar
  41. 41.
    Rigopoulos D, Katsambas A, Antoniou C, et al. Facial seborrheic dermatitis treated with fluconazole 2% shampoo. Int J Dermatol 1994; 33: 136–7PubMedCrossRefGoogle Scholar
  42. 42.
    Faergemann J, Jones JC, Hettler O, et al. Pityrosporum ovale (Malassezia furfur) as the causative agent of seborrhoeic dermatitis: new treatment options. Br J Dermatol 1996; 134 Suppl. 46: 12–5PubMedCrossRefGoogle Scholar
  43. 43.
    Gupta AK, Yokou M, Arika T, et al. Evaluation of the in vitro and in vivo efficacy of butenafine hydrochloride cream 1% against Malassezia furfur species and seborrheic dermatitis. J Dermatolog Treat 2000; 11: 79–83CrossRefGoogle Scholar
  44. 44.
    Aly R, Katz HI, Kempers SE, et al. Ciclopirox gel for seborrheic dermatitis of the scalp. Int J Dermatol 2003; 42 Suppl. 1: 19–22PubMedCrossRefGoogle Scholar
  45. 45.
    Abeck D. Rationale of frequency of use of ciclopirox 1% shampoo in the treatment of seborrheic dermatitis: results of a double-blind, placebo-controlled study comparing the efficacy of once, twice, and three times weekly usage. Int J Dermtol 2004; 43 Suppl. 1: 13–6Google Scholar
  46. 46.
    Altmeyer P, Hoffmann K. Efficacy of different concentrations of ciclopirox shampoo for the treatment of seborrheic dermatitis of the scalp: results of a randomized, double-blind, vehicle-controlled trial. Int J Dermatol 2004; 43 Suppl. 1: 9–12PubMedCrossRefGoogle Scholar
  47. 47.
    Lebwohl M, Plott T. Safety and efficacy of ciclopirox 1% shampoo for the treatment of seborrheic dermatitis of the scalp in the US population: results of a double-blind, vehicle-controlled trial. Int J Dermatol 2004; 43 Suppl. 1: 17–20PubMedCrossRefGoogle Scholar
  48. 48.
    Shuster S. A phase III, multinational, randomized, double-blind, vehicle-controlled study to assess the efficacy of ciclopirox shampoo for the treatment of seborrheic dermatitis/dandruff of the scalp. Proceedings of the 61st Annual Meeting of the American Academy of Dermatology; 2003 Mar 21–26; San Francisco. J Am Acad DermatolGoogle Scholar
  49. 49.
    Vardy DA, Zvulunov A, Tchetov T, et al. A double-blind, placebo-controlled trial of a ciclopirox olamine 1% shampoo for the treatment of scalp seborrheic dermatitis. J Dermatolog Treat 2000; 11: 73–7CrossRefGoogle Scholar
  50. 50.
    Dupuy P, Maurette C, Amoric JC, et al. Randomized, placebo-controlled, double-blind study on clinical efficacy of ciclopiroxolamine 1% cream in facial seborrhoeic dermatitis. Br J Dermatol 2001; 144: 1033–7PubMedCrossRefGoogle Scholar
  51. 51.
    Unholzer A, Varigos G, Nicholls D, et al. Ciclopiroxolamine cream for treating seborrheic dermatitis: a double-blind parallel group comparison. Infection 2002; 30: 373–6PubMedCrossRefGoogle Scholar
  52. 52.
    Crutchfield III CE. Pimecrolimus: a new treatment for seborrheic dermatitis. Cutis 2002; 70: 207–8PubMedGoogle Scholar
  53. 53.
    Meshkinpour A, Sun J, Weinstein G. An open pilot study using tacrolimus ointment in the treatment of seborrheic dermatitis. J Am Acad Dermatol 2003; 49: 145–7PubMedCrossRefGoogle Scholar
  54. 54.
    Marks R, Pearse AD, Walker AP. The effects of a shampoo containing zinc pyrithione on the control of dandruff. Br J Dermatol 1985; 112: 415–22PubMedCrossRefGoogle Scholar
  55. 55.
    Orentreich N, Taylor EH, Berger RA, et al. Comparative study of two antidandruff preparations. J Pharm Sci 1969; 58: 1279–80PubMedCrossRefGoogle Scholar
  56. 56.
    Satchell AC, Saurajen A, Bell C, et al. Treatment of dandruff with 5% tea tree oil shampoo. J Am Acad Dermatol 2002; 47: 852–5PubMedCrossRefGoogle Scholar
  57. 57.
    Al-Waili NS. Therapeutic and prophylactic effects of crude honey on chronic seborrheic dermatitis and dandruff. Eur J Med Res 2001; 6: 306–8PubMedGoogle Scholar
  58. 58.
    Conti-Diaz IA, Civila E, Asconegui F. Treatment of superficial and deep-seated mycoses with oral ketoconazole. Int J Dermatol 1984; 23: 207–10PubMedCrossRefGoogle Scholar
  59. 59.
    Ford GP, Farr PM, Ive FA, et al. The response of seborrhoeic dermatitis to ketoconazole. Br J Dermatol 1984; 111: 603–7PubMedCrossRefGoogle Scholar
  60. 60.
    Caputo R, Barbareschi M. Itraconazole: new horizons. G Ital Dermatol Venereol 2002; 137: 1–7Google Scholar
  61. 61.
    Scaparro E, Quadri G, Virno G, et al. Evaluation of the efficacy and tolerability of oral terbinafine (Daskil) in patients with seborrhoeic dermatitis: a multicentre, randomized, investigator-blinded, placebo-controlled trial. Br J Dermatol 2001; 144: 854–7PubMedCrossRefGoogle Scholar
  62. 62.
    Ghannoum MA, Kuhn DM. Voriconazole: better chances for patients with invasive mycoses. Eur J Med Res 2002; 7: 242–56PubMedGoogle Scholar
  63. 63.
    Gupta AK, Einarson TR, Summerbell RC, et al. An overview of topical antifungal therapy in dermatomycoses: a North American perspective. Drugs 1998; 55: 645–74PubMedCrossRefGoogle Scholar
  64. 64.
    McGrath J, Murphy GM. The control of seborrhoeic dermatitis and dandruff by antipityrosporal drugs. Drugs 1991; 41: 178–84PubMedCrossRefGoogle Scholar
  65. 65.
    Elewski BE. Mechanisms of action of systemic antifungal agents. J Am Acad Dermatol 1993; 28: S28–34CrossRefGoogle Scholar
  66. 66.
    Rosen T, Schell BJ, Orengo I. Anti-inflammatory activity of antifungal preparations. Int J Dermatol 1997; 36: 788–92PubMedCrossRefGoogle Scholar
  67. 67.
    Chosidow O, Maurette C, Dupuy P. Randomized, open-labeled, non-inferiority study between ciclopiroxolamine 1% cream and ketoconazole 2% foaming gel in mild to moderate facial seborrheic dermatitis. Dermatology 2003; 206: 233–40PubMedCrossRefGoogle Scholar
  68. 68.
    Faergemann J. Treatment of seborrhoeic dermatitis with oral terbinafine? Lancet 2001 Jul; 358 (9277): 170PubMedCrossRefGoogle Scholar
  69. 69.
    Nahm WK, Orengo I, Rosen T. The antifungal agent butenafine manifests anti-inflammatory activity in vivo. J Am Acad Dermatol 1999; 41: 203–6PubMedCrossRefGoogle Scholar
  70. 70.
    Abrams BB, Hänel H, Hoehler T. Ciclopirox olamine: a hydroxypyridone antifungal agent. Clin Dermatol 1992; 9: 471–7CrossRefGoogle Scholar
  71. 71.
    Gupta AK. Ciclopirox: an overview. Int J Dermatol 2000; 40: 1–7Google Scholar
  72. 72.
    Hanel H, Smith-Kurtz E, Pastowsky S. Therapy of seborrheic eczema with an antifungal agent with an antiphlogistic effect [in German]. Mycoses 1991; 34 Suppl. 1: 91–3PubMedGoogle Scholar
  73. 73.
    Korting HC, Grundmann-Kollmann M. The hydroxypyridones: a class of antimycotics of its own. Mycoses 1997; 40: 243–7PubMedCrossRefGoogle Scholar
  74. 74.
    Gupta AK, Skinner AR. Ciclopirox for the treatment of superficial fungal infections: a review. Int J Dermatol 2003; 42 Suppl. 1: 3–9PubMedCrossRefGoogle Scholar
  75. 75.
    Stuetz A, Grassberger M, Meingassner JG. Pimecrolimus (Elidel, SDZ ASM 981): preclinical pharmacologic profile and skin selectivity. Semin Cutan Med Surg 2001; 20: 233–41PubMedCrossRefGoogle Scholar
  76. 76.
    Nakagawa H, Etoh T, Yokota Y, et al. Tacrolimus has antifungal activities against Malassezia furfur isolated from healthy adults and patients with atopic dermatitis. Clin Drug Invest 1996; 12: 245–50Google Scholar
  77. 77.
    Butterfield W, Roberts MM, Dave VK. Sensitivities of Pityrosporum sp. to selected commercial shampoos. Br J Dermatol 1987; 116: 233–5PubMedCrossRefGoogle Scholar
  78. 78.
    Hammer KA, Carson CF, Riley TV. In vitro susceptibility of Malassezia furfur to the essential oil of Melaleuca alternifolia. J Med Vet Mycol 1997; 35: 375–7PubMedCrossRefGoogle Scholar
  79. 79.
    Baroni A, De Rosa R, De Rosa A, et al. New strategies in dandruff treatment: growth control of Malassezia ovalis. Dermatology 2000; 201: 332–6PubMedCrossRefGoogle Scholar

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© Adis Data Information BV 2004

Authors and Affiliations

  1. 1.Division of Dermatology, Department of MedicineSunnybrook and Women’s College Health Science Center (Sunnybrook site) and the University of TorontoTorontoCanada
  2. 2.Mediprobe ResearchLondonCanada

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