A New Perspective on Seborrheic Dermatitis Management

In a Dermatology Times Case-Based Peer Perspectives custom video series titled “Advancing Patient Outcomes in Seborrheic Dermatitis,” Raj Chovatiya, MD, PhD, MSCI, board-certified dermatologist and clinical associate professor at the Rosalind Franklin University Chicago Medical School, founder and director of the Center for Medical Dermatology and Immunology Research in Chicago, Illinois, and Dermatology Times Editorial Advisory Board member, provided a detailed look into the diagnosis and management of seborrheic dermatitis (SD). Drawing from his extensive experience, Chovatiya highlighted the prevalence of SD, the challenges in its diagnosis, the evolution of treatment options, and the critical role of patient-centric care.

Understanding Seborrheic Dermatitis

Chovatiya began by establishing the widespread nature of SD, noting that it affects approximately 5% of the global population. This high prevalence means dermatologists are likely to see multiple cases daily. SD can occur across all age groups, with distinct peaks in infancy (“cradle cap”), adolescence, and adulthood. Although the condition affects men and women with similar frequency, specific sociodemographic risk factors remain largely unstudied.

A significant challenge with SD is its variable presentation. It is often characterized by greasy, yellow-white scales and erythema, typically affecting the scalp, face, ears, and intertriginous areas. However, its appearance can mimic other inflammatory dermatoses, such as psoriasis or atopic dermatitis, leading to potential misdiagnosis. Additionally, the severity of symptoms, particularly itch, can be disproportionate to the visible signs, complicating both diagnosis and assessment of disease impact. Chovatiya emphasized that a definitive diagnosis relies on a careful consideration of signs, symptoms, location, and the chronic, relapsing-remitting course of the disease.

The Evolution of Treatment Options

Historically, the understanding of SD pathogenesis was limited, leading to a focus on treatments that either targeted the Malassezia yeast—once thought to be the primary cause—or inflammation. This resulted in a treatment landscape dominated by antifungal agents and topical corticosteroids or calcineurin inhibitors.

Although these traditional therapies can be effective for some, they have notable limitations. Over-the-counter (OTC) options may only be sufficient for mild cases. Prescription-strength corticosteroids, although potent, carry risks associated with long-term use, such as skin atrophy, striae, and dyspigmentation. The vehicles for many of these treatments, such as greasy creams or alcohol-based solutions, can be cosmetically unappealing and difficult for patients to add to their daily hygiene routines, especially on hair-bearing areas, leading to poor adherence.

“But the nice thing is that with a lot of evolving treatment options, we may be able to actually hit multiple things with 1 target,” Chovatiya said.

The recent approval of roflumilast foam, a phosphodiesterase 4 inhibitor, has introduced a new paradigm in SD treatment. This nonsteroidal option targets the underlying inflammatory pathways of the disease. Chovatiya highlighted its key advantages, which included the following:

• Efficacy:Clinical trial data show high rates of success, with approximately 80% of patients achieving clear or almost clear status (Investigator Global Assessment [IGA] success) and more than 50% achieving complete clearance (IGA 0) after 8 weeks of once-daily use. A significant majority of patients (64%) also experienced a clinically meaningful reduction in itch.
• Patient-friendly vehicle: The foam formulation is particularly well suited for treating hair-bearing areas such as the scalp and beard, improving patient adherence and satisfaction.
• Safety profile: Roflumilast foam has a favorable safety profile, with a low incidence of treatment-related adverse events.

Case 1: Widespread SD in a 22-Year-Old Man

Chovatiya presented 2 illustrative cases to demonstrate the real-world application of this new therapy. The first case involved a 22-year-old African American man with severe, widespread SD affecting his scalp, face, and eyebrows. His symptoms, including significant itch, were impacting his academic performance. He had previously shown minimal response to a ketoconazole shampoo and a hydrocortisone lotion. With this case, Chovatiya noted a critical point. SD in patients with darker skin tones may be underscored by investigators who are less familiar with how erythema presents in these populations. The patient’s high itch score and the impact on his quality of life underscored the need for a more effective and tolerable treatment. The patient was treated with roflumilast foam and achieved complete clearance and significant itch relief within 8 weeks.

Case 2: Severe Facial SD in a 28-Year-Old Man

The second case featured a 28-year-old White man with severe facial SD, including burning and flaking, who was embarrassed by his appearance and its effect on his relationships. He had been previously misdiagnosed with contact dermatitis and had tried multiple ineffective OTC remedies, from hydrocortisone cream to tea tree oil. This case highlighted the diagnostic uncertainty surrounding SD and the profound psychosocial impact it can have on patients. The patient was also successfully treated with roflumilast foam, achieving a near-clear status (IGA 1) and substantially reducing his itch and burning sensations.

These cases illustrate that roflumilast foam can serve as a highly effective, first-line, nonsteroidal option for patients with moderate to severe SD, particularly those who have not responded to traditional therapies or require a long-term solution without the risks of chronic steroid use. Chovatiya concluded that a patient-centered approach, which includes clear and honest conversations to understand a patient’s treatment preferences and the true impact of the disease on their life, is essential for successful management.