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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

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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.