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#351 Flaked out? Topical treatment for seborrheic dermatitis

How effective are topical treatments for adult facial or scalp seborrheic dermatitis?

About 40-50% of adults will have complete clearance of seborrheic dermatitis at 4 weeks with ketoconazole 2% or ciclopirox 1% compared to ~25% with placebo. Less studied interventions (metronidazole, corticosteroids, pimecrolimus) may be as effective but some have more adverse events (pimecrolimus, corticosteroids).

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  • 4 Systematic reviews1-4 of randomized controlled trials (RCTs). Results at 4 weeks and statistically different unless indicated.
    • Ketoconazole 2% (example: twice daily face, twice weekly scalp) 8 RCTs, 2520 patients:
      • Complete resolution:1 50% versus 28% placebo, number needed to treat (NNT)=5.
      • No statistical differences versus ciclopirox, topical corticosteroids, metronidazole.1
      • Other systematic reviews found similar.2,3
    • Ciclopirox 1% cream or shampoo (1% or 1.5%) (8 RCTs, 1525 patients):
      • Complete resolution:1 38% versus 21% placebo, NNT=6.
      • Others similar.2,3
    • Metronidazole 0.75% (2 RCTs, 131 patients):3
      • Improvement >75%: 39% versus 21% placebo, NNT=6.
    • Corticosteroids:2
      • Total clearance:
        • Mild steroid (example hydrocortisone 1%) versus strong steroid (examples betamethasone 0.05%, mometasone 0.1%, clobetasol 0.05%): No difference (2 RCTs, 93 patients).
        • Strong steroids: 50% versus 8% placebo (2 RCTs, 266 patients).
    • Pimecrolimus 1% (5 RCTs 48-96 patients, reported separately):
      • Reduction in clinical severity score (scale 0-6, lower better):
        • 4.8 versus 3.6 (methylprednisolone 0.1%).5
        • 4.8 versus 1.9 (metronidazole 0.75%).5
        • No difference6,7 versus vehicle or ketoconazole 2%.
      • Complete resolution (2 RCTs, 60 patients):
        • 84% versus 91% steroid (hydrocortisone 1%, betamethasone 0.1%): Not statistically different.2
    • Adverse events: Ketoconazole 2%.1
      • Versus placebo: No difference.
      • Dryness, pustules, pain: 5% versus 10% (corticosteroids).
      • Erythema, burning, prickling: 20% versus 67% (pimecrolimus 1%).7
  • Limitations: Small studies, inconsistent doses, randomization concealment and blinding often unclear.

  • Shampoos are rinsed 5-15 minutes after application, lotions applied on scalp as on skin.
  • Combining topicals (antifungal, anti-inflammatory) is commonly used despite minimal evidence.
  • Recurrences reduced8-10 with weekly selenium shampoo or ketoconazole 2%; or twice weekly ciclopirox 1% or tacrolimus 0.1%.
  • Cost (30 grams):11,12 Ketoconazole 2% ~$15; pimecrolimus 0.1% $95; hydrocortisone 1%, betamethasone 0.05% ~$18.
  • Other non-prescription shampoos have minimal evidence.13

Cristina Popa October 30, 2023

Great tip. I will start using it. Great option replacing steroids

Rami Ibrahim October 31, 2023


Pierre-Paul Tellier October 31, 2023

Thank you, clear evidence for what I have been doing for some time

Waguih Tannous October 31, 2023

Good review.

Razieh Poorandy October 31, 2023

Good article

tia renouf October 31, 2023


tia renouf October 31, 2023

well done

Omid YAHYAZADEH November 2, 2023

Very interesting

Memoona Butt November 4, 2023

Great research

Memoona Butt November 4, 2023

Good to know

Girma Mekonnen Tizazu November 14, 2023

Practical and helpful

Girma Mekonnen Tizazu November 14, 2023


Dr Jayantilal Changela January 9, 2024

excellent information and speakers as well thanks enjoyed conference Dr JJ Changlea

Vanessa Montagliani February 5, 2024


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  • Jennifer Young MD CCFP-EM
  • Émélie Braschi MD PhD
  • G. Michael Allan MD CCFP

1. Okokon EO, Verbeek JH, Ruotsalainen JH, et al. Cochrane Database Syst Rev. 2015; (5):CD008138.

2. Kastarinen H, Oksanen T, Okokon EO, et al. Cochrane Database Syst Rev. 2014; (5):CD009446.

3. Apasrawirote W, Udompataikul M, Rattanamongkolgul S. J Med Assoc Thai. 2011; 94(6):756-760.

4. Alsmeirat O, Lakhani S, Egaimi M et al. Cureus. 2022 Aug 2; 14(8):e27622.

5. Cicek D, Kandi B, Bakar, S, & Turgut D. J Dermatol Treat. 2009; 20(6), 344–349.

6. Warshaw EM, Wohlhuter RJ, Liu A, et al. J Am Acad Dermatol. 2007; 57(2):257-264.

7. Koc E, Arca E, Kose O, Akar A. J Dermatolog Treat. 2009; 20(1):4-9.

8. Massiot P, Reygagne P, Chagnoleau C, et al. Eur J Dermatol. 2023; 33(S1):13-18.

9. Joly P, Tejedor I, Tetart F, et al. J Am Acad Dermatol. 2021; 84(5):1278-1284.

10. Kim HO, Yang YS, Ko HC, et al. Ann Dermatol. 2015; 27(5):523-530.

11. LeBras M, Stone S. RxFiles:Antifungals: Treatment Chart. Available at:, Accessed on: October 15, 2023.

12. Regier L. RxFiles: Topical corticosteroids: comparison chart. Available at:, Accessed on: October 15, 2023.

13. Naldi L, Diphoorn J. Clinical Evidence. 2015; 05:1713.

Authors do not have any conflicts of interest to declare.