Seboroická dermatitida

Synonyma

• Seborrhoeic dermatitis
• Seborrheic dermatitis AmE
• Seborrhea
• "seborrheic eczema" [1]

Definice

• An inflammatory skin disorder
• Affecting the scalp, face, and trunk
• Typically scaly, flaky, itchy, red skin
• Affects the sebum-gland rich areas of skin. [1]

Výskyt

• Prevalence rate of seborrheic dermatitis is 3-5%
• Worldwide distribution
• The mildest form of this dermatitis, is probably far more common
• Present in an estimated 15-20% of the population [2]
• Slightly worse in males than in females [2]

Věk

Kojenci do 3 měs.

• Seborrheic dermatitis in infants, also called cradle cap, is a harmless, temporary condition. 3)
• It appears as thick, crusty, oily, yellow or brown scales over the child's scalp.
• Similar scales may also be found on:
• The eyelids
• Around the hairline
• Ear
• Around the nose
• In the groin 3)
• Cradle cap may be seen in newborns and small children up to age 3 3)
• Cradle cap is not contagious, nor is it caused by poor hygiene 3)
• It is not an allergy 3)
• It is not dangerous 3)
• Cradle cap may or may not itch. 3)
• Itching is not common among infants [1]
• If it itches, excessive scratching of the area may cause additional inflammation, and breaks in skin may cause mild infections or bleeding. 3)
• Uncommonly may present as a flexural eruption or erythroderma. [2]
• Frequently, a stubborn diaper rash accompanies the scalp rash [1]
• In infants the condition resolves itself within days and with no treatment [1]
• Many patients experience alternating periods of the symptoms [1]

Děti

• Seborrheic dermatitis is uncommon in preadolescent children, and tinea capitis is uncommon after adolescence, dandruff in a child is more likely to represent a fungal infection. A fungal culture should be completed for confirmation [2]

Dospělí

• The usual onset occurs with puberty
• It peaks at age 40 years and is less severe, but present, among older people. [2]
• May last from few weeks to even years
• Referred to a specialist when:
• It becomes painful
• The individual suspects that the skin might have become infected
• They have tried self-care therapy without success
• Can cause discomfort and interfere in one's daily activities
• prevent potentially long-lasting damage to the hair follicles which may lead to hair loss [1]

Příčiny

• Unknown

Zhoršující faktory

Stres

• Illness
• Psychological stress
• Fatigue
• Trauma škrábáním, ale i trauma lebky 3)
• Oily skin, infrequent shampoos or skin cleaning 3)
• Use of lotions that contain alcohol 3)
• Skin disorders (such as acne) 3)
• obesity may increase the risk 3)

• Reduced by:
• General health [1]

Výživa

• In children
• Excessive vitamin A intake can cause seborrhoeic dermatitis. [1]
• Nedostatek (vždy i riziko narušení mentálního vývoje = významné příčiny):
• Biotin
• pyridoxine (vitamin B6)
• riboflavin (vitamin B2) may also be a cause. [1]
• Nedostatek zinku !!!
• Především při postižení tváří / vzniku opruzenin / průjmech
• Nedostatek vit. B3 (niacinu) (pelagra) !!!
• Postižení tvářiček aj.

Provokující medikace

Various medications may flare or induce seborrheic dermatitis

• Auranofin
• Aurothioglucose
• Buspirone
• Chlorpromazine
• Cimetidine
• Ethionamide
• Gold
• Griseofulvin
• Haloperidol
• Interferon alfa
• lithium
• Methoxsalen
• Methyldopa
• Phenothiazines
• Psoralens
• Stanozolol
• Thiothixene
• Trioxsalen [2]
• Bepanthen (vlastní zkušenost)

Genetická dispozice

Environmental

• Changes in humidity
• Changes in seasons
• Activity is increased in winter and early spring, with remissions commonly occurring in summer. [2]

Hormonální vlivy

Neurologické vlivy

• Parkinson's disease
• One of the autonomic signs of Parkinson's disease [1]
• Stroke [1]

Imunitní systém

• Unfavourable epidermic response to the infection, with the skin becoming inflamed and flaking [1]
• With immunodeficiency (especially HIV) [1]
• The dermatitis appears early in persons with AIDS
• Affects 25-50% of persons with AIDS
• Has greater involvement and greater activity in those with diminished T-cell function
• Helper T cells, phytohemagglutinin and concanavalin stimulation, and antibody titers are depressed [2]

Malassezia furfur (formerly Pityrosporum ovale)

• Likely plays a key role [1]
• Its lipase activity—releasing inflammatory free fatty acids—and from its ability to activate the alternative complement pathway [2]
• Malassezia organisms are probably not the cause but are a cofactor linked to a T-cell depression, increased sebum levels, and an activation of the alternative complement pathway. Persons prone to this dermatitis also may have a skin-barrier dysfunction. [2]
• Main species found in the scalp is Malassezia globosa
• Malassezia globosa produces toxic substances that irritate and inflame the skin
• Patients with seborrhoeic dermatitis appear to have a reduced resistance to the yeast. [1]
• However, the colonization rate of affected skin may be lower than that of unaffected skin. [1]
• Saturated, not unsaturated, fatty acids support Malassezia growth [1]
• Pure, unsaturated FAs were unable to support growth of M. globosa or M. furfur.
• Interestingly, growth of both species was supported by saturated FAs. This is further evidenced by lard, which is rich in saturated triglycerides.
• Number density of M. globosa and M. restricta do not directly correlate to dandruff presence or severity [1]
• Removal correlates directly with amelioration of flaking
• In dandruff susceptible individuals
• Pure OA
• An unsaturated FA
• And Malassezia metabolite [1]
• Induces flaking in the absence of Malassezia
• Malassezia hydrolyze human sebum, releasing a mixture of saturated and unsaturated fatty acids. [1]
• They take up the required saturated FAs, leaving behind unsaturated FAs.
• The unsaturated FAs penetrate the stratum corneum and due to their non-uniform structure breach the skin's barrier function.
• This barrier breach induces an irritation response, leading to dandruff and seborrheic dermatitis.
• The widely present yeast, Malassezia furfur (formerly known as Pityrosporum ovale), is involved [1]

Klinika

• In adolescents and adults
• Scalp scaling (dandruff)
• Mild to marked erythema or "redness" of the nasolabial fold
• Especially during times of stress or sleep deprivation. [1]

• Gradually and usually the first signs of seborrheic dermatitis are
• The flakes of skin called dandruff [1]

• May occur anywhere on the skin of:
• The face
• Behind the ears
• In areas where the skin folds
• In more rare cases:
• Near the eyelashes
• On the forehead
• Around the sides of the nose
• Other body areas:
• The chest
• Upper back
• Basically on any part of the body where there is certain amount of hair and therefore follicles which might become inflamed.
• A sign that the condition has become more severe is:
• The formation of thick, oily and yellow scales
• Might appear on the forehead
• Around the sides of the nose
• On the skin near the eyelashes [1]

• The flakes can be
• Yellow
• White
• Grayish [1]

• In more severe cases
• Yellowish to reddish scaly pimples appear
• Along the hairline
• Behind the ears
• In the ear canal
• On the eyebrows
• On the bridge of the nose
• Around the nose
• On the chest
• On the upper back [1]
• Presternal or interscapular involvement is more common than nonscaling intertrigo of the umbilicus, axillae, inframammary and inguinal folds, perineum, or anogenital crease, which also may be present. [2]
• In some cases hair loss
• Patchy scaling
• Thick crusts on the scalp
• Red, greasy skin covered with flaky white or yellow scales
• Itching
• Soreness and yellow or white scales that may attach to the hair shaft [1]
• Hypopigmentation is seen in blacks [2]
• An annular or geographic petaloid scaling is the most common. A rare pityriasiform variety can be seen on the trunk and the neck, with peripheral scaling around ovoid patches, mimicking pityriasis rosea. [2]
• Infectious eczematoid dermatitis, with oozing and crusting, suggests secondary infection. [2]

Komplikace

• Secondary infection in the intertriginous areas and on the eyelids.
• Candidal overgrowth is common in infantile napkin dermatitis.
• Such children may have a diaper dermatitis variant of seborrheic dermatitis or psoriasis.
• Generalized seborrheic erythroderma is rare, often in association with:
• AIDS
• Congestive heart failure
• Parkinson disease
• Immunosuppression in premature infants [2]

Hair loss

• Side effects to inflammation may include temporary hair loss.
• If severe outbreaks are untreated for extended intervals, permanent hair loss may result, because of damage to hair follicles. [1]

Příčiny

• Yeast causing seborrheic dermatitis is the main cause of hair loss due to this condition
• Excess oil production by the oil glands due to reasons such as
• Hormonal imbalance
• Stress
• Extreme hot or cold weather conditions
• Weakened immune system
• Parkinson's disease
• Certain neurological conditions
• Keeping the scalp unclean [1]

Seborrheic blepharitis

• May respond to gentle cleaning of eyelashes with baby shampoo and cotton applicators [2]
• The use of ketoconazole cream in this anatomical region is controversial [2]

Treatments

Režim

• Early treatment of flares is encouraged
• Behavior modification techniques in reducing excoriations
• Use of hair spray or hair pomades should be stopped [2]
• Brush your child's hair with a clean, soft brush after each shampoo and several times during the day. 3)
• If scales do not easily loosen and wash off:
• Mineral oil to the baby's scalp and wrap warm, wet cloths around his head for up to an hour before shampooing
• Contact your physician if:
• Scales continue to be a problem
• Child seems uncomfortable or scratches his scalp 3)
• If patches of seborrheic dermatitis drain fluid or pus, form crusts, or become very red or painful 3)

Topical treatments

Shampoos

• Daily, gentle shampoos with a mild soap while scales are present when disappeared, twice weekly. 3)
• Longer period of lathering
• After lathering, let soak in for 10 min prior to rinsing :2::
• Effective shampoos are containing:
• Salicylic acid
• Tar
• Polytar
• Inhibiting T-lymphocyte activation
• Safer than topical steroids for prolonged use or in skin folds.
• selenium
• Selenium sulfide (2.5%)
• Sulfur
• "Konopný šampón na seborhoeu" (volně prod. v lékárně)
• Zinc
• Ketoconazole
• Nizoral šampón (volně prod. )
• Ciclopirox
• May help by reducing Malassezia yeast scalp reservoirs [2]
• Resorcin 3)
• May be used on truncal lesions or in beards
• May cause inflammation in the intertriginous or facial areas [2]

Okluze

• Overnight occlusion of:
• Tar
• Bath oil
• Baker's P&S solution
• May help to soften thick scalp plaques
• Derma-Smoothe F/S oil
• Especially helpful when widespread scalp plaques are present [2]

Gely

• 1% metronidazole gel
• Effective for seborrheic dermatitis of the face [2]
• Nonsteroidal cream [2]

Cleansers

Creams/lotions that contain:

• Antifungal
• Anti-inflammatory
• močovina
• Excipialy - například s mandlovým olejem
• Sebo-suppressive
• Keratolytic ingredients [1]

Sprej

• Clotrimazol AL spray 1% - lze ošetřit rozsáhlejší kožní plochy a skalp

1. Combinations of the usual agents

• A dandruff shampoo
• An antifungal agent
• Topical steroid [1]
• May hasten recurrences [2]
• May foster dependence because of a rebound effect [2]
• Are discouraged except for short-term use [2]

2. Short-term topical steroid in a "pulse fashion"

Class III

• Nonfluorinated steroid should be tried first
• Mometasone furoate (Elocon)
• Betamethasone
• Suppreses migration of polymorphonuclear leukocytes [2]
• Reverses capillary permeability [2]
• Affects production of lymphokines [2]
• Inhibitory effect on Langerhans cells [2]

Class I

• Extra-potent

Class II

• Once or twice per day, even on the face
• Must be stopped after two weeks because of the increased frequency of side effects
• If the patient responds before the two-week limit, the agent should be stopped immediately [1]
• Clobetasol propionate (Temovate)
• Fluocinonide (Lidex) [1]

Adjuvant therapy

Čištění skalpu

• Dandruff shampoo and an antifungal agent [1]
• Is essential during the "pulse" period
• Should be continued as maintenance therapy after each pulse [1]
• Maintaining the scalp clean is mandatory for sufferers of seborrheic dermatitis
• There are several special shampoos that contain: [1]
• Sulfur
• Zinc or salicylic acid
• A thorough cleaning of the scalp is the first step to be made in preventing and curing this condition
• By having a proper scalp hygiene, the bacteria and fungus are removed and the likelihood of developing a follicular inflammation is reduced [1]

Topical cortisone creams

• Class IV or lower corticosteroid creams, lotions, or solutions can be used for acute flares. [2]
• Highly effective in minimizing the symptoms of this condition, especially inflammation and itchiness [1]

Nonsteroidal anti-inflammatory agent

• Calcineurin inhibitors [2]
• Pimecrolimus [2]
• Currently indicated only for atopic dermatitis in immunocompetent patients >2 y. [2]
• Use cream sparingly to avoid maceration in skin folds. [2]
• Tacrolimus [2]
• Should not cause steroid-type skin atrophy
• Currently indicated only for atopic dermatitis in immunocompetent patients ? 2 y [2]
• Sulfur [2]
• Sulfonamide combinations [2]
• Propylene glycol [2]

Antimykotika

• Zinc pyrithione
• Salicylic acid
• selenium sulfide
• Ketoconazole 1%
• Ketoconazole cream 2% (Nizoral)
• Ketoconazole foam (Extina)
• Ketoconazole shampoo 2% (Nizoral 2%; prescription only in USA),
• Ketoconazole shampoo 1% (Nizoral A-D Shampoo; over-the-counter in USA) [2]
• Imidazole broad-spectrum antifungal [2]
• Inhibits synthesis of ergosterol, causing cellular components to leak [2]
• Climbazole
• Piroctone olamine
• Clotrimazole
• Sulfur
• Ciclopiroxolamine
• Sodium sulfacetamide
• Terbinafine
• Fluconazole
• Itraconazole [1]
• Naftifine [2]
• Systemic ketoconazole or fluconazole may help if seborrheic dermatitis is severe or unresponsive [2]
• 400 mg of oral ketoconazole daily for 2 weeks [2]

Další medikace

• Coal tar
• Can be very effective
• Is not advised to be used for a prolonged time
• Is carcinogenic
• Lithium gluconate
• Lithium succinate
• Vitamin B6 ointment
• Topical steroid
• Chronic treatment with topical corticosteroids may lead to permanent atrophy and telangiectasia of the skin.
• Pimecrolimus, brand name Elidel
• Isotretinoin (Accutane)
• At low dose 5 mg to 10 mg
• As a last resort in refractory disease
• Sebosuppressive agent
• Potentially serious side effects [1]

Phototherapy

• UV-A and UV-B laser
• Red and blue LED light
• Inhibit the growth of Malassezia
• Reduce the inflammation [1]

Natural treatments

• Aloe Vera applied topically
• Tea tree oil
• Diluted to 5% applied topically
• Viola tricolor or Heartsease
• Applied topically
• Recognised by Germany's Commission E as Monograph 195 for the treatment of Cradle Cap a form of seborrheic dermatitis.
• Honey
• Apply diluted crude(raw)honey
• 90% honey diluted in warm water
• Every other day on the lesions with gentle rubbing for 2-3 mins
• Honey is left on for 3 hr before gentle rinsing with warm water
• Treatment is continued for 4 weeks.
• Avocado Extracts
• AV119 & 5-alpha Avocuta, also known as butyl avocadate applied topically
• Monarda fistulosa [1]

Supplements

• Lactobacillus casei
• Lactobacillus paracasei
• Lactoferrin
• Vitamin B7 - Biotin
• Vitamin B6
• Vitamin B2
• Vitamin B3: Nicotinamide, also known as Niacinamide (významné !!)
• Zinc [1] (velmi významné !!!)

Diet

• Relationship between seborrheic dermatitis and intestinal yeast, such as candida
• Antifungal diet
• Elimination of sugar
• Foods rich in antioxidants and beta-carotene [1]

Alternative treatments

• milk of magnesia [1]
• Droždí (velmi účinné)
• Povařené (mrtvé) droždí
• Omývání vyrážky na obličeji a přidávání do příkrmů

Prevention

• Good hygiene and daily use of over-the-counter or prescription anti-fungal shampoo:
• Nizoral
• Medicated Selsun Blue
• Medicated Head & Shoulders
• Regular stays in the sun are beneficial to healing
• UV-radiation (especially in the winter) is recommended by doctors
• Very short hair cut (more air and sun comes to the concerned areas)
• Frequent hair washing - at least every two days [1]

Diferenciální diagnóza

• Asteatotic Eczema
• Lichen Simplex Chronicus
• Atopic Dermatitis
• Lupus Erythematosus, Acute
• Seborrheic derm. may appear as a butterfly rash, similar to the acute facial eruption associated with systemic lupus erythematosus. [2]
• Candidiasis, Cutaneous
• Nummular Dermatitis
• Contact Dermatitis, Allergic
• Pemphigus Erythematosus
• Contact Dermatitis, Irritant
• Pemphigus Foliaceus
• Dermatologic Manifestations of Gastrointestinal Disease
• Perioral Dermatitis
• Dermatomyositis
• Pityriasis Rosea
• Drug Eruptions
• Rosacea
• Drug-Induced Photosensitivity
• Tinea Capitis
• A skin biopsy may be needed in persons with exfoliative erythroderma, and a fungal culture can be used to rule out tinea capitis [2]
• Erythrasma
• Tinea Corporis
• Extramammary Paget Disease
• Tinea Cruris
• Glucagonoma Syndrome
• Tinea Versicolor
• Impetigo
• Intertrigo [2]
• Pelagra !!! (při postižení obličeje aj.)
• Deficit zinku !!! (postižení obličeje, opruzeniny ap.)

• Xerotic eczema
• Chronic granulomatous disease
• Exfoliative erythroderma
• Facial chapping
• Infectious eczematoid dermatitis
• Letterer-Siwe disease
• Letterer-Siwe disease in infants may manifest as a scaling scalp and purpura. [2]
• Activation of complement [2]
• Scaling drug eruptions
• Staphylococcal blepharitis
• Tinea amiantacea
• Tinea versicolor
• Vitamin B and/or zinc deficiency [2]
• Sebopsoriasis (psoriasis) is distinguished by dermatopathologic findings:
• Regular acanthosis
• Thinned rete ridges
• Exocytosis
• Parakeratosis
• An absence of spongiosis
• Neutrophils may be seen in both diseases [2]

Bioptické vyšetření

• Dermatopathologic findings of seborrheic dermatitis are nonspecific:
• Hyperkeratosis
• Acanthosis
• Accentuated rete ridges
• Focal spongiosis
• Parakeratosis

Literatura: