#351 Flaked out? Topical treatment for seborrheic dermatitis

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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).
- Total clearance:
- 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%.
- Reduction in clinical severity score (scale 0-6, lower better):
- Ketoconazole 2% (example: twice daily face, twice weekly scalp) 8 RCTs, 2520 patients:
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- Complete resolution (2 RCTs, 60 patients):
- 84% versus 91% steroid (hydrocortisone 1%, betamethasone 0.1%): Not statistically different.2
- Complete resolution (2 RCTs, 60 patients):
- 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
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- 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