It can be distressing to experience the inflamed flaky scalp and patches of greasy flaky, red skin that occur with seborrheic dermatitis. This common skin condition impacts about 11% of the population, especially infants under three months of age- when the condition is coined cradle cap, and adults ages 30 to 60.
Seborrheic dermatitis causes patches of red skin covered with greasy scales that can itch and flake off. It is common on the scalp, where it causes dandruff, and in oily areas of the body, including the face, sides of the nose, eyebrows, ears, eyelids, and chest. Conventional therapies, including -azole antifungals, low-potency steroid creams, and topical calcineurin inhibitors, are commonly used but may have side effects and require ongoing use.
Fortunately, an integrative approach to this chronic condition can help to uncover contributing factors and address them with diet and lifestyle changes, supplements, light therapy, and stress-management practices.
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What is Seborrheic Dermatitis?
Seborrheic dermatitis is a common skin condition that causes a flaky scalp and patches of greasy flaky, red skin, most commonly in areas of the body that are rich in oil glands, including the face, sides of the nose, eyebrows, ears, eyelids, and chest. The most common manifestation of mild seborrheic dermatitis is dandruff which causes white and yellow scales of skin to flake off of the scalp. On the skin, seborrheic dermatitis causes greater inflammation with swelling and discolored skin in addition to the greasy, flaky patches.
Seborrheic dermatitis most commonly occurs in two age groups–cradle cap in infants under three months old and adult seborrheic dermatitis in adults ages 30 to 60.
Infantile seborrheic dermatitis or cradle cap usually appears early in life, within the first two weeks after birth, and lasts around four to six months. It can cause a yellowish crust and scale on the skin of the face, diaper region, creases of the neck, and armpits. When cradle cap forms, the crown and front of the scalp may be covered with a thick yellowish scale crust that is greasy and adherent. Although very noticeable, it is usually not itchy or painful and resolves with time.
Adult seborrheic dermatitis most commonly develops on the face (especially around the nose, middle of the eyebrows, ears, and forehead), scalp, and chest, where there are the most oil glands. In adults, the condition is often chronic, with a relapsing appearance of the scaly areas, especially during the winter and early spring seasons or with intense stress.
Signs & Symptoms of Seborrheic Dermatitis
Symptoms of seborrheic dermatitis in adults can include:
- Patches of greasy red skin with white flakes and/or yellow scales or crust, most commonly on the face, sides of the nose, middle of the eyebrows, ears, eyelids, chest, armpits, groin, under the breasts, and other parts of the body with oil glands
- Underlying rash that can appear red in those with light skin and darker or lighter in people with brown or Black skin
- Flaking skin (dandruff) on the scalp, hair, eyebrows, beard, or mustache
- Scaly redness on the edges of the eyelids (blepharitis)
- Inflammation around hair follicles on the cheeks and the upper half of the torso
- Itchiness
These skin findings may come and go over long periods of time and flare up with changes in season, stress, or fatigue. The skin rash tends to be worse in colder, drier climates, with common improvement during warmer weather when there is greater exposure to sunlight.
Symptoms of seborrheic dermatitis, or cradle cap, in infants often include:
- A yellowish crust and scale on the skin of the face, diaper region, creases of the neck, and the armpits
- Underlying reddish rash In lighter skin tones and rash that is darker than the natural skin tone, purple or white in darker skin
- Thick yellowish scale-crust that is greasy and adherent across the crown and front of the scalp that may spread to cover the entire scalp (cradle cap)
What Causes Seborrheic Dermatitis?
Seborrheic dermatitis is a chronic and relapsing condition that involves inflammation and an immune reaction in the skin.
An inflammatory immune response to yeasts like Malassezia (Pityrosporum) that live on the skin is thought to play a role in the development of seborrheic dermatitis. These yeasts feed on sebum, an oily substance made of high amounts of squalene, wax esters, and triglycerides that help keep skin from drying out. People with more oily skin or greater sebum production are at an increased risk of developing seborrheic dermatitis. In addition to yeasts that live on the skin, changes in the balance of the bacteria within the skin microbiota are thought to play a role.
In addition, genetics, stress, climate, hormonal fluctuations, and alcohol consumption contribute to the inflammation, immune response, and skin changes that occur in this condition. A family history of psoriasis or other forms of dermatitis is associated with a greater risk. Periods of intense stress and dry air during colder weather seem to contribute to flares of the condition, while sunlight exposure leads to decreased skin findings since the sun’s UV-A and UV-B rays kill the yeast. Hormone fluctuations can also trigger flare-ups of seborrheic dermatitis.
Seborrheic dermatitis is more common in people with HIV or other immunosuppression such as post-organ transplant, Downs syndrome, lymphoma, anorexia nervosa, depression and other mood disorders, rosacea, psoriasis, and neurological conditions like Parkinson’s disease and epilepsy. Alcohol consumption also increases the risk of developing seborrheic dermatitis.
What is The Guts Role in Healthy Skin?
The gut and skin both host diverse communities of microbiomes that work in harmony to maintain overall health. These two organs are also closely related and influence each other in a communication network coined the gut-skin axis. When imbalances or dysbiosis occur in either microbiome, immunity, and inflammation can become disturbed, and seborrheic dermatitis may develop.
Malassezia has immune cross-reactivity with Candida yeast that is common throughout the body and in the gastrointestinal tract. Studies suggest that people with seborrheic dermatitis have higher levels of immune markers (antigens) to Candida in their stool and on their tongues, reflecting an overgrowth of Candida in their gut microbiomes. Additional support for the involvement of yeast overgrowth in seborrheic dermatitis comes from research showing improvement in some patients when treated with oral anti-fungal/yeast medications. Further, a clinical study found significant improvements in the severity and symptoms of moderate to severe dandruff in people who took Lactobacillus paracasei probiotics.
In addition, food sensitivities and a leaky gut barrier can disrupt this balanced interaction, increasing inflammation and contributing to a wide array of skin disorders such as atopic dermatitis, psoriasis, acne vulgaris, and skin cancer. For example, although cradle cap is usually self-limited and resolves within a few months, studies suggest that children with untreated food allergies can continue to show symptoms for years.
Functional Medicine Labs to Test That Can Help Individualize Treatment for Seborrheic Dermatitis
Functional medicine testing can help uncover factors contributing to the imbalanced inflammation and immunity at the root of seborrheic dermatitis.
Comprehensive Assessment of Gut Health
A comprehensive gut health test like the GI-MAP provides a stool analysis of gut microbes, along with markers of dysbiosis, inflammation, and intestinal permeability, via measuring zonulin, a protein that impacts the permeability of the gut lining. Looking at the composition of the gut microbiome can allow for an assessment of pathogenic and commensal bacteria, yeasts, and parasites that allows for the identification of any imbalances in the gut microbiota, known as dysbiosis, which may be contributing to skin inflammation.
Hormone Testing
Since changes in hormones can contribute to flare-ups of seborrheic dermatitis, hormone testing can help establish any imbalances that can be targeted with treatment. Androgen hormones such as DHEA, testosterone, and dihydrotestosterone (DHT) may play a role in seborrheic dermatitis since they increase sebum production. The DUTCH Complete is a dried urine hormone test that evaluates how hormones are metabolized and can tell you if an increase in sex hormones is influencing sebum production or contributing to flare-ups.
Organic Acids Testing
Organic Acids Testing provides a comprehensive metabolic panel that looks at levels of metabolites formed during the body's cellular processes. These compounds (organic acids) can be measured in the urine and indicate the efficiency of various metabolic pathways, including those influenced by gut microbiota. For example, this test measures levels of short-chain fatty acids (SCFAs) like butyrate that are critical for maintaining a healthy gut barrier and modulating systemic inflammation to maintain healthy skin health.
Inflammation Testing
C-Reactive Protein (CRP) is a protein made by the liver as a response to inflammation in the body. Elevated CRP levels reflect systemic inflammation that can occur with seborrheic dermatitis, dysbiosis, and leaky gut. Repeat measurement of CRP levels can help with monitoring treatment and assessing the effectiveness of interventions aimed at mitigating inflammation and improving skin health.
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The Importance of Collaborative Care For The Treatment of Seborrheic Dermatitis
To address inflammatory skin conditions such as seborrheic dermatitis in the most effective way, collaborative care integrating conventional dermatology and integrative medicine offers a comprehensive look at factors that impact the skin and overall health.
Seborrheic Dermatitis Treatment: Conventional Medicine
The conventional approach to treating seborrheic dermatitis is tailored to the area of the body that is affected and how severely the skin is affected. Treatment aims to reduce the skin signs like flakiness, redness, and greasiness while also reducing itching. Ongoing treatment is often needed to deal with this chronic condition.
In adults with seborrheic dermatitis of the face or body, conventional medications like topical keratolytic, antifungals, corticosteroids, and calcineurin inhibitors are used.
Topical keratolytics, like salicylic acid or lactic acid, may be used to help reduce oil production from sebaceous glands.
Topical antifungals like ketoconazole or sertaconazole are available in creams, foams, or gels that are applied to the affected areas twice daily for up to eight weeks and then as needed.
Topical corticosteroids like betamethasone valerate, desonide, fluocinolone, or hydrocortisone can be applied to the skin in the form of creams, lotions, foams, gels, ointments, oils, or solutions once or twice a day.
When used long-term, corticosteroids can cause skin thinning and loss of skin color, so topical calcineurin inhibitors like pimecrolimus cream (Elidel®) or tacrolimus ointment (Protopic®) are often used as an alternative. These are not a first-line option, though, as there is concern about an increased risk of cancer and potential kidney damage with their use.
In widespread and/or severe cases of seborrheic dermatitis, antifungals may be taken as a pill for systemic effects.
Recurring cases of seborrheic dermatitis that impacts the scalp may be prescribed antifungal shampoos that contain ciclopirox (Loprox®) or ketoconazole (Nizoral®) used daily for several weeks and then intermittently to prevent flare-ups. If the dandruff is more severe or persistent, prescription medicated shampoos containing betamethasone valerate (Luxiq®), clobetasol (Clobex®), fluocinolone (Capex®), or fluocinolone solution (Synalar®) are often used. These shampoos are often very drying and can increase the risk of hair breakage.
Integrative and Complementary Approach to Seborrheic Dermatitis
An integrative medicine approach to seborrheic dermatitis incorporates dietary modifications, supplements, and natural topical treatments that can help restore balance to the gut-skin access, reduce inflammation, and reduce skin symptoms.
Dietary Modifications for Seborrheic Dermatitis
Research suggests that diet and nutrition impact inflammatory skin diseases like seborrheic dermatitis. Imbalanced gut bacteria, infections, food allergies, and/or leaky gut can contribute to the underlying inflammation and oxidative stress that occurs in seborrheic dermatitis.
A personalized anti-inflammatory diet like the Mediterranean Diet emphasizes plenty of whole fresh vegetables and fruit while avoiding processed foods and additives, as well as foods that one is allergic to or sensitive to, caffeine, and alcohol to nourish the microbiome and balance inflammation.
Gut microbes are crucial in regulating body-wide inflammation, so probiotic-rich foods like kimchi and sauerkraut help to support the balance of the bacteria in your gut. One approach that helps to restore a balanced microbiome is the Microbiome Diet. This involves a three-phase approach to restoring gut health by first starting with an elimination diet that removes foods that interfere with the gut microbiome's equilibrium and then introducing foods rich in prebiotic and probiotic elements and fermented foods.
Since oxidative stress plays a role in many skin conditions, fruits and vegetables that are rich in antioxidants reduce inflammation and are beneficial for inflammatory skin diseases. For example, a cross-sectional study found that females who eat a more "Western" dietary pattern which includes more meat, potato, and alcohol consumption, have more seborrheic dermatitis, whereas higher fruit intake is associated with less seborrheic dermatitis. Additional research also shows that alcohol consumption increases the risk of developing seborrheic dermatitis.
Supplements and Herbs
Probiotics, especially those containing Lactobacillus paracasei show potential for reducing flares of dandruff. Analyzing gut microbes with functional medicine testing can guide individualized treatment to rebalance the gut microbiome and help reduce skin inflammation.
Supplements like l-glutamine, slippery elm, and aloe help to repair the lining of your digestive tract to heal a leaky gut that is contributing to inflammation and autoimmunity that underlies seborrheic dermatitis.
Myo-inositol supplementation can help balance androgens to regulate sebum production and reduce inflammation. Inositols are also naturally found in grains, fruits, and nuts.
Triphala is a poly-phenol-rich prebiotic blend of three herbs (Emblica officinalis (Amalaki), Terminalia bellerica (Bibhitaki), and Terminalia chebula (Haritaki)) that helps to nourish beneficial bacteria in the gut microbiome. It is used in traditional Ayurvedic medicine for many purposes, including immunomodulating, antibacterial, and antimutagenic. A study showed that eight weeks of supplementation with triphala resulted in statistically significant reductions in scalp sebum production in people with seborrheic dermatitis.
Stress Management Techniques
Chronic stress has a significant impact on immune function and inflammation that impacts many skin conditions, including seborrheic dermatitis. Incorporating stress management practices that are meaningful for you, such as yoga, breath work, tai chi, prayer, or movement in nature, can help balance stress hormones and reduce inflammation.
Essential Oils for Seborrheic Dermatitis
As a natural antifungal agent, tea tree oil can be added to shampoo at a ratio of 5% to treat affected areas, although it may cause allergic reactions in some people. Studies have shown that tea tree oil has antifungal activity, including against Malassezia. To avoid contact dermatitis, undiluted tea tree oil should not be applied directly to the skin.
Other anti-fungal oils, such as rosemary or cedarwood, can also be used in shampoos or oils applied to the skin or scalp.
Extra virgin olive oil, avocado oil, or unrefined coconut oil can help to control dandruff and remove scales from your hair in affected areas. Coconut oil contains medium-chain fatty acids such as lauric acid and capric acid that have antifungal properties which reduce excess yeast. Apply to your scalp, and leave it in for 1 to 3 hours before washing out.
Aloe vera gel is another natural approach that can be applied topically to soothe affected skin.
Light Therapy for Seborrheic Dermatitis
Phototherapy using a specific wavelength of ultraviolet light is applied to the skin to help decrease inflammation. Studies have shown that narrow-band UVB phototherapy is an effective and safe treatment for severe seborrhoeic dermatitis. Another approach to reducing sebum production involves phototherapy using the photosensitizer indole-3-acetic acid and green light, which has been shown to be a safe and effective therapeutic option for facial seborrhoeic dermatitis.
Medicated Shampoos for Seborrheic Dermatitis
In adults, mild cases of dandruff that impact the scalp are often treated with over-the-counter shampoos containing selenium sulfide ((Head & Shoulders, Selsun Blue), zinc pyrithione (DermaZinc, Head & Shoulders), or coal tar. Selenium sulfide shampoo aims to treat infection and relieves itch but comes with common side effects such as hair loss and discoloration, and skin irritation. Similarly, zinc pyrithione shampoo is antifungal and antibacterial to address dermatitis but can irritate the skin in some people. Coal tar is a keratolytic agent that softens the protein keratin on the skin to help dead skin cells slough off more easily.
Melaleuca alternifolia or tea tree oil shampoo has been studied and shown to result in statistically significant improvements in dandruff, with no adverse effects reported.
In addition to tea-tree oil-based shampoos, shampoo containing an extract of Solanum chryotrichum has been shown to have similar effects as commercial anti-fungal shampoos for the treatment of dandruff.
Overall, it is helpful to avoid shampooing too often so that your scalp can clear without drying out. Many people’s scalp stays most balanced when shampooing about every two to three days so that your natural oils are maintained at a balanced level.
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Summary
Seborrheic dermatitis is a chronic, recurring, inflammatory skin condition due to an immune response to yeast that feeds off oils on the skin. It results in redness and skin flaking in areas of the skin with oil glands like the face, chest, and back. Skin that is impacted looks red and greasy with flaky white or yellow scales. On the scalp, seborrheic dermatitis causes flaking and a yellow greasy scale known as dandruff or cradle cap in infants.
The risk of seborrheic dermatitis is increased in people with health conditions that affect their immune systems and raise inflammation, such as HIV or psoriasis. Other factors that can bring on a flare of the condition include significant stress, changes in seasons, and hormonal shifts.
A functional medicine approach to seborrheic dermatitis can help uncover factors contributing to immune dysfunction and inflammation, such as imbalances in the microbiome of the gut. Integrative treatments can then be targeted at discovered imbalances to help resolve symptoms.
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