Table 3.

Treatment of seborrheic dermatitis and dandruff.

Medication			Dose/ Formulation	Regimen	Mechanisms	Side Effects	References
TOPICAL	Antifungals	Ketoconazole	2% Shampoo, cream, gel or foam	Scalp or skin: Twice/week × 4 weeks, then once/week for maintenance.	Inhibition of fungal cell wall synthesis.	ICD† in <1% of patients. Itching, burning sensation and dryness in 3% of patients.	[2,8,26,97–101]
		Bifonazole	1% shampoo, cream or ointment	Scalp: every other day or once daily. Skin: once daily.		ICD in 10% of patients.	[8,26,99,102]
		Miconazole	Cream	Skin: 1–2 times daily.		ICD, itching, burning sensation.	[47,97,103]
		Ciclopirox Olamine	1.5% shampoo, cream, gel or lotion	Scalp: 2–3 times/week × 4 weeks, then once/week for maintenance. Skin: twice daily.	Inhibition of metal-dependent enzymes.	ICD in <1% of patients. Itching, burning sensation in 2% of patients.	[8,47,97,99,104,105]
		Selenium sulfide	2.5% shampoo	Scalp: Twice/week × 2 weeks, then once/week × 2 weeks. Repeat after 4–6 weeks.	Cytostatic and keratolytic.	ICD in ~3% of patients. Orange-brown scalp discoloration.	[8,97,106,107]
		Zinc Pyrithione	1% shampoo	Scalp: 2–3 times/week.	Increased cellular copper interferes with iron-sulfur proteins.	ICD in ~3% of patients.	[8,97,99,101,108,109]
	Cortico-steroids	Hydrocortisone	1% cream	Skin: 1–2 times daily.	Anti-inflammatory, anti-irritant.	Risk of skin atrophy, telangiectasias, folliculitis, hypertrichosis, and hypopigmentation with prolonged use.	[8,9,97,99,103,108]
		Betamethasone dipropionate	0.05% lotion	Scalp and skin: 1–2 times daily.			[8,47,110]
		Desonide	0.05% lotion, gel	Scalp and skin: 2 times daily.			[8,111–113]
		Fluocinolone	0.01% shampoo, lotion or cream	Scalp or skin: Once or twice daily.			[7,114]
	Immuno-modulators	Pimecrolimus	1% cream	Skin: 1–2 times daily.	Inhibition of cytokine production by T-lymphocyte.	Risk of skin malignancy and lymphoma with prolonged use.	[47,98,115–118]
		Tacrolimus	0.1% ointment	Skin: 1–2 times daily × 4 weeks, then twice/week for maintenance.			[26,97,109,118–120]
	Miscellaneous	Coal tar	4% shampoo	Scalp: 1–2 times/week.	Antifungal, anti-inflammatory, keratolytic, reduces sebum production.	Local folliculitis, ICD on fingers, psoriasis aggravation, skin atrophy, telangiectasias, hyper-pigmentation. Risk of squamous cell carcinoma with prolonged use.	[4,8,47,117,121]
		Lithium gluconate/succinate	8% ointment or gel	Skin: twice daily × 8 weeks.	Anti-inflammatory via increased IL-10 and decreased TLR2 and TLR4 in keratinocytes.	ICD in <10% of patients.	[8,122–124]
		Metronidazole	0.75% gel	Skin: twice daily × 4 weeks.	Anti-inflammatory via inhibition of free radical species.	Rare contact sensitization with prolonged use.	[5,47,125,126]
		Phototherapy	UVB: Cumulative dose of 9.8 J/cm2	Three time/week × 8 weeks or until clearing.	Immuno-modulation and inhibition of cell proliferation.	Burning, itching sensation during/after therapy. Risk of genital tumor with prolonged use.	[26,127–129]
SYSTEMIC		Itraconazole	Oral: 200 mg	Once daily × 7 days, then once daily × 2 days/month for maintenance.	Inhibition of fungal cell wall synthesis. Anti-inflammatory via inhibition of 5-lipoxygenase metabolites.	Rare liver toxicity.	[97,130,131]
		Terbinafine	Oral: 250 mg	Once daily × 4–6 weeks or 12 days monthly × 3 months.	Inhibition of cell membrane and cell wall synthesis.	Rare tachycardia and insomnia.	[132–134]

Note: Shampoos, foams and lotions are better suited for treating seborrheic dermatitis and dandruff on the scalp; gels, creams and ointments are used to treat seborrheic dermatitis on body locations other than the scalp.

^†ICD: Irritant Contact Dermatitis.