“Hi Doctor, I have suffered from severe scalp and facial itch for a while, which has already led to sleep disturbance.” said from my old patient “Hao” scratching his head while stepping into my clinic.
“Have you been staying up late or having a stressful life?”
“Unfortunately, yes. My father is in critical condition due to a stroke and requires intensive care. My brothers prefer palliative treatment only, which I could not agree to, especially when I thought of as all my father’s life is struggling so hard just to raise us up. As time goes by, the doctor now tells me that my father cannot stay in the hospital anymore and is required to be transferred to a nursing home along with a tracheostomy. Neither one of my brothers cares about the situation and I’m the only child in charge of everything. I am too stressed to sleep tight and my skin gets more and more itchy.”
I patted his back to show my praise.
“Luckily, God stands by me, so I’m doing Okay!” he said with a bitter smile.
After talking through with him and making proper prescriptions for him. By watching his leave, I couldn’t help but think that “Hao, you definitely are not doing Okay! Your skin tells everything!”
What is seborrheic dermatitis? Fungal infection + Inflammation
The incidence of seborrheic dermatitis is about 1-3%, which is higher in men. Although it is called “dermatitis”, it combined feature of both fungal infection and inflammation.
Uncover the Cause
|The causes of seborrheic dermatitis|
|Fungal infection Malassezia (Pityrosporum), dysbiosisSebum over prodctionNeuropsychiatric diseaseSeasonal alterationsInadequate cleansingHormoneStay up late, stressful lifeHepatitis CPsoriasisImmuno-supressionOrgan transplantationHIV/AIDS|
The causes of seborrheic dermatitis included heavy workload, busy life, staying up late, stressful lifestyle, over-exhaustion because of child care or family care, etc. The top three referral sources of seborrheic dermatitis in the inpatient dermatologic consultation are department of neurology, department of surgery and department of psychology, and these patients often have conditions in combination with brain trauma, stroke or depression. Therefore, it is obvious that seborrheic dermatitis really is closely associated with our emotions and neurological well-being.
Seborrheic dermatitis is closely associated with scalp psoriasis. Although the two conditions may have overlapping clinical manifestations, there are a few different features to help us differentiate them in clinical practice:
Common lesion sites: Scalp, face, upper body
Seborrheic dermatitis usually presents as erythematous plaques in combination with yellowish greasy scales. The lesion sites distribute symmetrically in areas rich in sebaceous glands, e.g. scalp, face (eyebrows, area between eyebrows, bilateral nasal alar, and cheeks, ears, and mustache areas), upper body (anterior chest, armpits), umbilicus and pubic area. These oil-producing areas create a preferable environment for Pityrosporum Sporumovale to grow.
What is Pityrosporum Sporumovale?
Pityrosporum Sporumovale is a normal skin flora that prefers living in a oily environment. It can be found in 75–98% of the healthy population without causing any diseases. However, once the colony starts to overgrow, the ability to skin protection becomes compromised, consequently leading to epidermal proliferation and dermatitis (caused by the metabolites of Pityrosporum Sporumovale). In addition, Pityrosporum Sporumovale overgrow is closely associated with the severity of seborrheic dermatitis.
The treatment for seborrheic dermatitis requires covering three aspects: Strategic medications, uncover the causes and lifestyle modification.
Seborrheic dermatitis is a chronic, repetitive and quite annoying disease caused by stress, emotions, Western diet and poor physical conditions. Stressful life may aggravate the status of dermatitis. As the therapeutic effects of medications only work for a short-period, uncovering causes from daily living and lifestyle modification along with topical remedies are the main stay for long-term maintenance and the prevention of seborrheic dermatitis.
Strategic medications: Be aware of the drug resistance of anti-fungal agents and the side effects of steroids
The treatment can be divided into acute-flare up control, long-term maintenance and prevention.
Factors such as the efficacy, ease of application, safety of medication, and the patient’s age will be considered by dermatologists upon making prescriptions. Patient’s compliance and a good doctor-patient relationship are also essential to achieve a successful treatment.
There are a few types of topical agents, which can be divided into four major categories based on their mechanisms of actions: sterilization agents/bacteriostatic agents, anti-inflammatory agents, anti-allergic/soothing agents and cellular stabilizers.
As seborrheic dermatitis is associated with pityrosporum infections along with inflammation, conventional treatment is mainly based on the topical anti-fungal agents and steroids.
Topical anti-fungal agents are less likely to cause irritation, which can be applied to sensitive skin or babies. However, as Pityrosporum Sporumovale is one of the normal skin flora, it cannot be completely terminated. In that case, long-term application may rise the concern of drug resistance.
Topical steroid is a fast-acting agent. However, significant side effects (e.g. skin or scalp sensitivity, skin atrophy, vasodilation, folliculitis, prone to infection, etc.) may present after long term use. Topical steroid is only recommended as a short-term remedy for acute conditions, and the dose and frequency must be tapered gradually when the inflammation is relieved.
For patients who are vulnerable to repeated infections, frequent flare up, have steroidphobia, steroid side effects or resistance of anti-fungal, alternative choices including non-steroidal topical agents (e.g., Elidel Cream, Protopic Ointment), anti-allergic soothing agents (e.g., 5α Juniper Scalp Puryfying Liquid Shampoo which contains glycyrrhetinic acid, Sebclair), or other medications or cosmetics containing cellular stabilizers (e.g. pinetarsol gel) giving us another thought of scalp skin care. By proper skin care and modulation, not only drug resistance and side effects could be prevented, but the recurrence can be reduced.
As various shampoos may have different effect, it is recommended to follow the instructions of dermatologists and use the products alternatively and properly to maximize the efficacy.
For patients with poor responses to topical agents, we can try oral isotretinoin, oral anti-fungal agents (itraconazole or fluconazole for about one week), or use adjuvant phototherapy .
A small change every day keeps the seborrheic dermatitis away: Nine tips for lifestyle modification
- Stay regular, do exercises, relieve stress and avoid staying up late, quit smoking and alcohol drinking.
- Eat light and avoid spicy, irritating or greasy food.
- People with greasy hair can increase the frequency of hair wash. For example, for those who used to wash hair once every other day may try to wash the hair once daily.
- Use only warm or cold water to wash hair.
- Stop scratching or using peeling products: abnormal keratinization during the onset of seborrheic dermatitis often results in scaling. Scratching or using peeling products only makes dermatitis even worse. These excoriated wounds could eventually lead to folliculitis or cellulitis.
- Do not get hair coloring or perm during the flare of seborrheic dermatitis or the condition will get worse.
- When having dermatitis, all skin care products are suggested to be suspended. Prophylactic or gentle products may be applied after the inflammation is relieved for long term relieving. The use of complex skin care products during the onset of dermatitis do no good to our diseased skin.
- Therefore, the use of gentle shampoo without irritating components but better with therapeutic/soothing/anti-allergic formula under the instructions of the dermatologist is recommended.
- Steroids and anti-fungal agents are not recommended as long-term agents. Regular follow-up visits are required to proper prescription adjustment.
Hao’s itchy scalp has improved greatly when I saw him at the clinic again.
“How is your father?”
“He’s doing better now. After settling down in the nursing home with the government subsidy, our life is gradually getting back on track. My scalp itch is finally not a problem for me.”
I modified Hao’s prescriptions to long-term maintenance medications and shampoo along with my bless, hopefully that both he and his father will all be good.
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Speaker- Dr. Wan-Yi Chou introduction
China Medical University Hospital (CMUH)- Bachelor of Medicine
Best Intern of CMUH
Resident of the Department of Pathology and Dermatology, CMUH
Best resident of CMUH
Research fellowship, Department of Dermatology, Nation Taiwan University Hospital
Attending Physician, Department of Dermatology, CMUH
Attending physician, Aesthetic medical and surgery center, CMUH
Attending Physician, Department of Dermatology, CMUH
Attending Physician, CC Skin and ADHC Dermatology Clinic (present)
Member of Taiwan Dermatology Association
Acne, cosmeceuticals, sensitive skin, scalp and hair, nail disease and nail brace