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Am Fam Physician. 2017;95(5):329

Author disclosure: No relevant financial affiliations.

Clinical Question

What is the most effective topical medication for adults with seborrheic dermatitis of the face or scalp?

Evidence-Based Answer

Steroids and antifungal agents can be used to effectively treat seborrheic dermatitis. Calcineurin inhibitors are as effective as steroids, but have a higher incidence of short-term adverse effects. (Strength of Recommendation: A, based on systematic reviews of randomized controlled trials [RCTs].)

Evidence Summary

A systematic review (36 RCTs, N = 2,706) compared topical therapies for seborrheic dermatitis in patients older than 16 years.1 Three trials comparing potent and mild steroids found that they were more effective than placebo for total clearance of skin lesions with short-term treatment (relative rate of clearance = 3.8; 95% confidence interval [CI], 1.2 to 11.6) and long-term treatment (relative rate of clearance = 2.2; 95% CI, 1.1 to 4.6). The following drug classes were equally effective in achieving total clearance: potent vs. mild steroids, steroids vs. azoles, and steroids vs. calcineurin inhibitors. The most common adverse effects in all treatment groups were redness, burning, and itching at the application site. The only significant difference in adverse effects occurred with short-term use (less than four weeks) of steroids vs. calcineurin inhibitors; steroids were 78% less likely to cause adverse effects (two trials, N = 60; relative risk = 0.22; 95% CI, 0.05 to 0.9).

Another systematic review (eight RCTs, N = 1,667) compared the clinical effectiveness of three topical antifungals (ketoconazole, metronidazole, and ciclopirox) with placebo in treating seborrheic dermatitis in patients 15 to 78 years of age.2 After four to eight weeks of treatment, there was significant improvement (75%) with all three antifungals compared with placebo (relative rate of clearance = 1.8 to 5.8). Limitations of this review include poor-quality trials with marked heterogeneity, as well as lack of head-to-head trials.

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