Rosen & Barkin's 5-Minute Emergency Medicine Consult (637 page)

Infants with seborrheic dermatitis and cradle cap may present with concurrent atopic dermatitis

TREATMENT

None required

None required

• Seborrheic dermatitis is a chronic condition:
  
  • Emergent treatment is not required unless secondary infection or erythroderma is present
    

• Pharmacologic options are often utilized in a multifaceted approach
  
• Therapy is directed at decreasing the reservoir of lipophilic yeast and the sebum that supports its growth, thus reducing inflammation and improving hygiene
  
• Severe cases may require removing scales and cornified nonviable epithelium to facilitate further treatment
  
• Scales may be softened by applying mineral oil (overnight if necessary) prior to washing
  
• Gentle brushing with a soft brush (toothbrush) or fine-tooth comb after washing may help remove stubborn scales
  
• Patient education:
  
  • Early treatment when condition flares
    
  • Emphasize hygiene and demonstrate proper cleansing of scaly lesions
    
  • Moderate UV-A/UV-B sunlight exposure may be beneficial as it inhibits growth of
    Malassezia
    yeasts
    
  • Refrain from hair sprays and hair pomades
    
• Infantile seborrheic dermatitis:
  
  • Responds readily to shampoos, emollients, and mild topical steroids
    
  • Aggressive keratolytic or mechanical removal may cause further inflammation
    
• Adult seborrheic dermatitis:
  
  • Treatment aimed at controlling symptoms, rather than curing the condition
    
• Blepharitis:
  
  • Warm to hot compresses to affected areas
    
  • Gentle cleansing with baby shampoo and cotton tip debridement of thick scale
    
• Cradle cap in infants:
  
  • Topical olive oil (as emollient)
    
  • Topical imidazoles
    
  • Low-potency topical corticosteroids
    
• Scalp findings in children & adults:
  
  • Topical shampoos:
    
    • Pyrithione zinc
      
    • Coal tar
      
    • Salicylic acid
      
    • Selenium sulfide
      
    • Ciclopirox
      
    • Ketoconazole
      
• Nonscalp findings in children & adults:
  
  • Topical antifungals ± corticosteroids
    
  • Topical calcineurin inhibitors
    

• Imidazoles:
  
  • Inhibits ergosterol synthesis of fungal cell membrane
    
  • Target
    Malassezia
    species:
    
    • Ketoconazole 2% topical
      
    • Nizoral, Extina, Xolegel
      
• Topical corticosteroids:
  
  • Skin atrophy, striae, hypopigmentation, and telangiectasia may occur with extended use
    
  • Higher-potency agents indicated only for refractory conditions to less-potent agents
    
  • Use only briefly, as frequent use may foster recurrence and rebound effect
    
  • Use low-potency agents on areas with thinner skin (e.g., skin folds, neck, face):
    
    • Hydrocortisone 0.5%, 1%, 2.5%
      
  • Consider high- to mid-potency agents only on areas of thicker skin (e.g., trunk, scalp):
    
    • Fluocinolone acetonide
      
    • Triamcinolone acetonide
      
    • Betamethasone dipropionate
      
    • Clobetasol propionate
      
• Pyrithione zinc*:
  
  • Reduces epidermal cell turnover
    
  • Antifungal & antibacterial properties
    
• Salicylic acid*:
  
  • Keratolytic properties
    
  • Useful in areas where scaling and hyperkeratosis are prominent
    
• Selenium sulfide*:
  
  • Reduces epidermal and follicular corneocyte production
    
  • Antifungal properties
    
• Coal tar/liquor carbonis detergens (LCD)*:
  
  • Inhibits mitotic cell division
    
  • Antipruritic, antiseptic properties
    
  • Reduces epidermal thickness
    
  • Avoid on face, skin flexures, or genitalia
    
• Sulfur/sulfonamide combinations:
  
  • Prevents PABA to folic acid conversion via dihydropteroate synthase inhibition:
    
    • Carmol scalp treatment
      
    • Ovace
      

*These agents are contained alone or in combination in formulations of the following:

• Denorex
  
• Head & Shoulders
  
• Neutrogena T/Gel or T/Sal
  
• Selsun Blue
  

• Ciclopirox:
  
  • Anti-fungal, -bacterial, -inflammatory effects
    
• Topical calcineurin inhibitors:
  
  • Anti-inflammatory & antifungal properties
    
  • Lack long-term effects of corticosteroids
    
  • Black box warning concerning malignancy:
    
    • Pimecrolimus 1%
      
    • Tacrolimus 0.1%
      

FOLLOW-UP

Admission unlikely to be required unless severe secondary infection or erythroderma is present

Patients may be discharged with recommended medications and follow-up

• Refer patients to primary care physician when considering underlying illness or comorbidities
  
• Consider referral to a qualified dermatologist when the diagnosis remains elusive or the condition fails to respond to therapy
  

• Symptoms should improve within 7–10 days, but may take months to resolve completely and may recur
  
• Adolescent and adult forms may persist as a chronic dermatitis
  
• Provide return precautions for signs of secondary bacterial or fungal infections:
  
  • Fever, erythema, tenderness, or ulcerations
    

• Severe and sudden attacks of seborrheic dermatitis may be the initial presentation of an immunocompromised patient (e.g., HIV/AIDS)
  
• Admission may be warranted for further evaluation of the underlying disease process
  

• Elewski BE. Safe and effective treatment of seborrheic dermatitis.
  Cutis.
  2009;83:333–338.
  
• Goldsmith LA, Katz SI, Gilchrest BA, et al.
  Fitzpatrick’s Dermatology in General Medicine.
  8th ed. New York, NY: McGraw-Hill; 2012.
  
• Hurwitz S.
  Clinical Pediatric Dermatology.
  3rd ed. Philadelphia, PA: Elsevier Saunders; 2006.
  
• Naldi L, Rebora A. Clinical practice. Seborrheic dermatitis.
  N Engl J Med
  . 2009;360:387–396.
  

CODES

• 690.10 Seborheic dermatitis, unspecified
  
• 690.11 Seborrhea capitis
  
• 690.12 Seborrheic infantile dermatitis
  

BASICS

• Generalized seizures:
  
  • Classically tonic–clonic (grand mal)
    
  • Begin as myoclonic jerks followed by loss of consciousness
    
  • Sustained generalized skeletal muscle contractions
    
  • Nonconvulsive generalized seizures:
    
    • Absence seizures (petit mal); alteration in mental status without significant convulsions or motor activity
      
• Partial seizures:
  
  • Simple:
    
    • Brief sensory or motor symptoms without loss of consciousness (i.e., Jacksonian)
      
  • Complex:
    
    • Mental and psychological symptoms
      
    • Affect changes
      
    • Confusion
      
    • Automatisms
      
    • Hallucinations
      
    • Associated with impaired consciousness
      
• Status epilepticus:
  
  • Variable definitions:
    
    • Seizure lasting longer than 5–10 min
      
    • Recurrent seizures without return to baseline mental status between events
      
  • Life-threatening emergency with mortality rate of 10–12%
    
  • Highest incidence in those <1 yr and >60 yr of age
    
• At least one-half of patients presenting to the ED in status do not have a history of seizures.
  
• Alcohol withdrawal seizures (“rum fits”):
  
  • Peak within 24 hr of last drink
    
  • Rarely progress to status epilepticus
    
• Patients with a single seizure have a 35% risk of recurrent seizure within 5 yr