"The heart break of seborrhea"or was it psoriasis? For the number of times the commercial played in the 70's, it should be indelibly etched into my memory. Suffice it to say, the ad was all about dandruff. Dandruff with its flaking, itching, scaling and redness afflicting either scalp or face, is most commonly the result of seborrhea, (or seborrheic dermatitis, the medically correct terminology), affecting an estimated 5% of the world's population.

Seborrhea is an inherited condition that affects the rate of production of skin cells. For the many who think their problem is actually due to "dryness", visible flaking is really due to a buildup of proliferating cells that have nowhere to go. This is why all the moisturizer in the world won't help resolve seborrheic dermatitis.

The Whys Of Seborrhea

I often compare this to a "short circuit" in the genetic programming of skin cells. Periodically, and usually unpredictably, the skin of the scalp and/or face begins to reproduce itself faster than normal. When this takes place, the extra epidermal cells can't be shed innocuously, so flakes appear.

Seborrheic dermatitis appears on sebum-rich areas of the scalp, face, and trunk. Sebum production begins at puberty, triggered by circulating DHT (the activated testosterone metabolite). Lipid rich sebum nourishes normal skin yeast, Pityrosporum ovale. Flourishing numbers of yeast produce lipase, an enzyme used to break down sebum into digestible free fatty acids (FFA). Unfortunately, FFAs are irritating to the skin resulting in inflammation - hence the itch, scratch cycle.

Patients with seborrheic dermatitis also have an abnormal immune response with reduced activity of helper T cells and activation of the alternative complement pathway.

FLARE FACTORS

Anyone can have seborrhea at any time for absolutely no reason. In fact, the sheer unpredictable nature of the condition is often maddening for patients. However, there is no doubt that there are definitely trigger factors that can cause seborrheic dermatitis to flare.

• Seasonal Changes

  Seasonal changes unquestionably play a role in flaring seborrheic dermatitis. Part of this is due to diminished UV light during the winter. Ultraviolet rays help reduce the rate of cellular turnover, explaining why the condition is at its best during the summer. Cold weather also dehydrates the skin, exaggerating the appearance of flaking. And finally, cold and flu season is coincidentally at its peak, perhaps confusing the picture.

• Illness and Infection

  Both viral and bacterial infections can affect the immune system and trigger a bout of seborrhea. It's not that the skin is infected, but the body's generalized response to it.

• Stress

  An increase in stress leads to an elevation in circulating levels of DHT, making for more sebum that P. ovale can feast upon and more FFAs to irritate the skin.

• Hormonal Swings

  Progesterone is on a rise just before one's menstrual cycle begins and during pregnancy. Higher levels of progesterone make for higher levels of DHT to stimulate the sebaceous glands and trigger a flare of seborrhea.

  The use of DERMAdoctor Calm Cool & Corrected Anti-Redness Tranquility Cream can help address increased oiliness, blemishes, scaling and itching during this time.

  Nordihydroguiaretic acid (NDGA) is a natural, plant derived lipooxygenase inhibitor, meaning it's function is to reduce inflammation and has been detailed in journal articles such as The Journal of Biochemistry and Pharmacology (March 2002) to possess the ability to reduce 5-alpha reductase function; the enzyme responsible for changing testosterone into DHT.

  Oleanolic acid according to a journal article out of the University of Kansas department of Toxicology and Pharmacology may work to help reduce inflammation and help reduce lipid (fatty acid) levels.

• Neurological Conditions

  Conditions including paralysis, Alzheimer's, Parkinson's and stroke may be associated with a more generalized or noticeably chronic case of seborrhea.

• HIV Infection

  Patients with HIV already have a reduced t helper cell count. So a condition like seborrhea is likely to be far more significant in a patient already genetically predisposed. Excellent maintenance therapy with a variety of treatments targeting the underlying causes can help improve the appearance of seborrheic dermatitis for these patients.

• Medication

  Many medicines can trigger a flare of seborrhea. These may include psoralens, lithium, interferon, griseofulvin, tagamet, gold, methyldopa, chlorpromazine, haldol and phenothiazines. If you suspect that a medication is flaring your seborrheic dermatitis, ask your doctor before stopping your therapy.

TREATMENT

Unfortunately, there is nothing you can do in daily life that can prevent seborrhea. And since this is a genetically programmed condition, it is only controllable, not curable. However, adequate treatment should be able to control seborrhea and keep skin and scalp looking its best.

My personal seborrhea treatment philosophy revolves around my experience that the condition responds best to a "cocktail" of therapeutic agents. Combining products with different modes of action works in a complimentary fashion, improving responsiveness.

Using a variety of shampoos with varied active agents works better than relying upon a single shampoo alone. There aren't too many of my patients who ever responded to a single shampoo or treatment. Keep a few of your favorites in the shower and alternate them as you please. No need to get caught up on which day for which brand. Dandruff shampoos can take their toll upon the hair. It is fine to use a conditioner or cream rinse after washing with a medicated shampoo. DHS Conditioning Rinse is great if you want a lightweight conditioner. If you have color-treated or severely dry hair, use Korres Shea Butter & Vitamins Nourishing & Hydrating Hair Mask instead.

I also look to simplicity and what makes sense for one's lifestyle. If the regimen doesn't fit one's way of life, it won't last for long. This is particularly important for African Americans who often find themselves in a quandary of how to handle their scalp care due to styling limitations. Shampooing daily is out of the question for all but the worst conditions. I urge these patients to shampoo weekly with a medicated dandruff shampoo and supplement with daily topicals to gain control of the condition.

• Zinc Pyrithione

Zinc pyrithione is a dermatology staple in the treatment of seborrheic dermatitis. It is thought that it has multifunctional abilities to help reduce the rate of skin cell proliferation, has anti-yeast properties targeting P. ovale, creating an environment hostile to further growth of the yeast and may also help exfoliate cellular debris.

Therapy options are varied which works well depending upon areas one is focusing treatment.

For the scalp, pyrithione zinc provides excellent therapy and is available in several excellent shampoos including DHS Zinc Shampoo and DermaZinc Shampoo.

Daily shampooing may not be possible for a variety of reasons. The use of a zinc based spray solution is a terrific way to supplement shampooing. Whether the shampoo is zinc pyrithione based, steroid based or other medicated option, applying DermaZinc - Advanced Formula Zinc Therapy Spray/Drops to the scalp (skip applying to the hair shaft, aim for the roots and scalp instead) offers an additional therapy to gain control over dandruff.

Facial scaling (especially beard area for men) and even the infrequent case of body seborrhea (most common on the male torso or on patients with neurological complaints) can benefit from washing with a zinc pyrithione based cleanser like DERMAdoctor Born To Be Mild Medicated Face & Body Cleanser. Once a day use is plenty; overuse may dry the skin. Another treatment option is applying DermaZinc Cream. Gain the moisture thanks to the cream base and the therapy provided from the zinc pyrithione.

• Tar

  Tar has long been used in seborrhea therapy for its ability to reduce cellular proliferation. Tar shampoos run the gamut and include such excellent products as Ionil-T Shampoo, Ionil-T PLUS Shampoo and Neutrogena T/Gel Extra Strength Therapeutic Shampoo.

• Exfoliating Agents

  Alpha hydroxy acids (typically glycolic acid) and beta hydroxy acid (aka salicylic acid) help dissolve the "glue" that bonds cells together within thick crusts and allows cellular debris to be invisibly exfoliated away. Aqua Glycolic Shampoo & Body Cleanser contains glycolic acid, helping eliminate flaking and also helps reduce oiliness. Ionil Plus Shampoo and Neutrogena T/Sal Therapeutic Shampoo with 3% Salicylic Acid are all excellent salicylic acid based options. Korres Hair and Scalp Scrub for the Regulation of Dandruff & Sebum Secretion is a scrub for the scalp that uses physical means and feels wonderful!

• Antibacterial Therapies

  Reduce the number of bacteria and yeast upon the skin and disrupt a major factor in the formation of seborrhea as well as sebopsoriasis (a form of psoriasis that arises on the face and resembles seborrheic dermatitis).

  An abundance of antibacterial/antiyeast seborrhea treatments are now on the market Ketoconazole, an antiyeast medication can be found in Nizoral A-D Shampoo, containing 1% ketoconazole as well as prescription 2% Nizoral Shampoo and 2% Nizoral Cream.

  Carmol Deep Cleansing Antibacterial Shampoo contains 10% urea and triclosan to help debride scale and kill bacteria and yeast.

  Prescription Ovace is a sulfa-based cleanser that kills bacteria and is indicated in the treatment of seborrheic dermatitis. Anyone allergic to sulfa should avoid this therapy option.

  Over the counter home treatments can include topical Lamisil AT which kills fungus and yeast; miconazole cream, an antiyeast cream and sulfur based products (these are not related to sulfa) such as Rezamid. Be wary of these latter 2 options - they can be overly drying, so don't overdo it. Washing with a selenium sulfide based shampoo can also help kill P. ovale upon the skin.

• Steroids

  Reducing inflammation temporarily reduces itching and discomfort associated with seborrhea. A host of topical steroid solutions packaged in "Visine-like" bottles about, most of them prescription-only. Just 5-8 drops are randomly scattered on the scalp twice a day when shampoos aren't enough to control the condition. Once clear, the drops are shelved until the next bout. These steroid solutions vary widely in their strength, and I select one based upon the severity of the condition. One way to "steroid-spare" is to alternate with DermaZinc and ultimately wean off the steroid solution, relying upon the zinc instead.

  A steroid-based shampoo (again prescription) originally called FS shampoo, and now renamed Capex, is also something I combine into a patient's regimen. The steroid helps diminish the inflammation that accompanies the process. I usually have an individual shampoo daily for one week with the FS Shampoo, and then use it 1-2 times a week thereafter, using their prescription Nizoral shampoo, and even their DHS shampoo on different days.

  Very low potency topical steroid creams and lotions may be used upon the face, avoiding the eyes, for a week or two. My favorite Rx option is Desowen lotion applied twice daily. Long-term use should be avoided to prevent steroid atrophy (thinning of the skin). Cortaid is one option to consider for short-term relief.

• Scalp Masks

  While more commonly seen in psoriasis, thick crusting can form with seborrhea, too. Sometimes one simply needs something to cut through the crust to allow other treatments access to the scalp in order to work. P&S Liquid can be used nightly for 3-5 nights in a row if needed. Phenol blended with mineral oil helps remove scale, which can be easily shampooed away the next morning.

  Prescription Dermasmooth FS Oil is a high potency steroid scalp oil provides another nocturnal option. For African American patients, I may also suggest this as a temporary medicated oil that can double as a styling oil.

• Immunomodulators

  The new Immunomodulators, Protopic and Elidel may offer a possible prescription therapy option for severe seborrheic dermatitis, particularly of the face. While not FDA approved for use for this condition, they would be theoretically capable of helping gain control of a generalized case in an "off label" use.

Remember, seborrhea is controllable not curable. Each individual will have his or her own pattern (or lack thereof) of recurrence. Best-case scenario management is simply shelving topical steroids and relies upon medicated shampoos until the need to restart arises. Early intervention when symptoms first appear is ideal.

In chronic cases, routine use of therapeutic shampoos and treatments that can limit the need for topical steroid use and keep skin clear and comfortable it the goal. Things change and so does seborrhea. It is always fine to try to temporarily stop treatment once clear and take a wait-and-see approach. You can always restart them if necessary.

Thank you for taking the time to read my newsletter. As always, I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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