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A mother brings her 2 month old child to you with unsightly seborrhoeic dermatitis on his/her scalp. You prescribe 1% hydrocortisone but the mother expresses her unhappiness at using steroids. You remember that the dermatologists at your hospital like to use an antifungal cream and you decide to find out more.
Structured clinical question
In infants with seborrhoeic dermatitis [patient] is there any advantage to using topical antifungals [intervention] over steroids [comparison] to cure seborrhoeic dermatitis of the scalp and prevent recurrences [outcome]?
Medline 1966–2003 (Ovid).
Subject heading “seborrhoeic dermatitis” + subheadings “therapy AND drug therapy”; 556 articles produced and sorted manually: 5 relevant; see table 2.
Cochrane database and Best Bets website under keyword “seborrhoeic”. No further papers.
Seborrhoeic dermatitis is a common benign condition of childhood. Often the most appropriate treatment is to do nothing; however, children with scalp seborrhoeic dermatitis still make regular presentations to paediatric outpatient clinics with disease burden enough to warrant treatment.
The link between the excessive presence of Pityrosporum ovale yeast to seborrhoeic dermatitis is well documented in the literature and it is intuitive that using a pityrosporicidal agent would not only treat the condition, but help prevent recurrences. Both fungicides and steroids have been shown to be effective in the treatment of seborrhoeic dermatitis when compared to placebo.
Five trials of good quality were found directly comparing topical steroids with topical fungicides. At one month of treatment, four of the trials showed good effectiveness of both treatments and no significant differences between them. One trial (Ortonne et al) showed a very slight improvement in the ketoconazole group over the steroid group.
The trials reviewed are all on adults as there are no comparable trials in infants. However, the extrapolation to this age group is viable as the disease is similar. Only one paper (Zeharia et al), with a specifically paediatric age group could be found and the quality was too low to allow meaningful analysis.
The three studies which also looked at the recurrence rate showed similar results in two and a slight advantage in using ketoconazole in one. Two trials noted low and similar incidence of side effects and one (Ortonne et al) showed a much better tolerance of the antifungal over the steroid.
There is no clear consensus on treatment regimen. However, a four week course was shown to be effective in four of the trials using a once or twice a day regimen.
There has been a paper published on the safety of ketoconazole in infants (Brodell et al) which showed that a course of ketoconazole twice a week for four weeks produced no detectable serum ketoconazole levels and no change in LFTs.
CLINICAL BOTTOM LINE
Ketoconazole is at least as effective at treating seborrhoeic dermatitis as steroid creams and may be better at preventing recurrences, providing a good alternative to using steroid creams in infants.