Antifungals are the mainstay of treatment
Because there is no cure for SD, the goal of therapy is to control the dermatitis. Topical antifungal agents are used to suppress the Malassezia yeast and topical steroids are used to suppress inflammation. Azole antifungal medications such as ketoconazole are effective and can be used for long periods of time with minimal risk of adverse effects3-5 (strength of recommendation [SOR]: C).
Our patient had used nystatin cream, which is effective against Candida yeast infections, but not especially effective for Malassezia sp.6
To reduce inflammation, mild topical steroids such as hydrocortisone cream 2.5% should be used. However, they must be used for short periods to avoid atrophy, telangiectasias, and steroid-induced acne. An alternative evolving treatment is to use a calcineurin inhibitor, such as pimecrolimus cream 1% or tacrolimus ointment 0.1%. These drugs do not exacerbate hypopigmentation, an effect that sometimes is attributed to topical steroids.7
Scalp treatments include shampoos such as ketoconazole 2%, selenium sulfide 2.5%, and ciclopirox 1%.3 Shampoos should be lathered up and left on the scalp for 3 to 5 minutes before rinsing.
Two forms of ketoconazole for our patient
Our patient responded well to ketoconazole cream 2% applied twice daily to the face and other areas without hair and ketoconazole 2% shampoo twice weekly. At a 6-week follow-up, the patient had significant improvement in scaling and pruritus on the central face and scalp. The associated facial hypopigmentation faded over 3 months.
CORRESPONDENCE
Robert T. Brodell MD, Division of Dermatology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216; rbrodell@umc.edu
