Seborrheic dermatitis, often referred to as dandruff, is a common problem for many women with brown skin. Areas of involvement are the hairline and scalp, as well as the eyebrows (Figure 1), the area between the nose and corners of the mouth (Figures 2) (nasolabial folds) and the ears. Less often the middle of the chest and neck are involved. In some women, seborrheic dermatitis appears as thick, greasy yellowish flakes and in others as fine, thin whitish flakes (Figures 3). In individuals with lighter shades of brown skin, redness may be seen along with the flaking. Most often, however, the areas that are involved are lighter (hypopigmentation) or darker (hyperpigmentation) than the normal skin tone. The longer the condition is left untreated, the greater the hypo- or hyper-pigmentation which is more noticeable in people of color. Hypo- and hyper-pigmentation usually resolves when the problem is treated.

The symptoms that women with seborrheic dermatitis complain of include scalp itching and dryness, and in some cases, hair breakage and loss. Once seborrheic dermatitis is treated the symptoms resolve.

Cause
Although the cause of seborrheic dermatitis is uncertain, it has been attributed to the presence of the yeast, Malassezia furfur (pityrosporum ovale) (Figure 4). Since Malassezia is found in normal skin as well as that affected by seborrheic dermatitis, an immune reaction to the yeast organism is postulated to predispose certain individuals to the condition.

In brown skin, seborrheic dermatitis is sometimes confused with other skin disorders. These include eczema, the fungal infection, tinea versicolor and the subacute cutaneous form of lupus. In many African American and Latino children, seborrheic dermatitis is often confused with tinea capitis (ringworm). However, in childen, dandruff occurs infrequently and in this case, flaking of the scalp is likely due to the fungus, tinea capitis.

Treatment
For women with brown skin, over-the-counter dandruff shampoos are the first line of treatment. However, they may dry the hair shaft contributing to further hair breakage so having the proper shampooing technique is important (see below). Topical oil-based products designed to “oil-the-scalp” may initially mask symptoms of dryness and flaking but eventually lead to worsening of other symptoms such as itching and inflammation. Therefore, the practice of oiling-the-scalp” is not recommended.

Shampoos
In women with naturally straight hair, daily or every other day shampooing is an acceptable treatment for seborrheic dermatitis. However, for women with curly, tightly coiled, pressed or relaxed hair, shampooing daily is often not permissible. For women with these hair types, once or twice weekly shampooing with an over-the-counter or prescription shampoo for seborrheic dermatitis until the condition improves is appropriate. Over the counter shampoo products that have demonstrated efficacy in the treatment of seborrheic dermatitis include zinc pyrithione, tar, salicylic acid, selenium sulfide and ketaconazole containing preparations. Prescription shampoos containing either a corticosteroid or an antifungal medication are effective for seborrheic dermatitis that has not responded to OTC shampoos. The primary prescription  therapy for the treatment of scalp seborrheic dermatitis are the anti-fungal shampoos containing either ketoconazole 2% (Nizoral) or the newer ciclopriox (Loprox). These shampoos focus on the fungus that may cause seborrheic dermatitis. Loprox Shampoo works well in women with brown skin because of its gentle fragrance and dye free formulation that omits harsh ingredients.

Many of the shampoos commonly used for the treatment of seborrheic dermatitis as outlined above, are very harsh on chemically treated hair or the tightly coiled hair of women of color. Therefore, contact with the hair may be minimized by applying the shampoo to the scalp, ears and areas behind the ears, lathering and rinsing off after 5 minutes. Then, a conditioning shampoo may be applied to wash the actual hair. This should be followed by the application of a moisturizing conditioner to the hair for 10 minutes. With this method of washing, avoidance of contact of the medicated shampoo with the hair will minimize the drying effect of the shampoo on often brittle hair.

Proper Shampoo Technique for Seborrheic Dermatitis
1. Shampoo once or twice weekly with a medicated shampoo until the condition improves
2. Lather the scalp (ear area as well if involved), minimizing contact of the medicated shampoo with the actual hair
3. Allow the medicated lather to stay in contact with the scalp for 5 minutes
4. Rinse the medicated lather out and then wash the hair with a conditioning shampoo and rinse
5. Condition the hair for 10 minutes
6. Apply topical medication as prescribed by your doctor

Topical corticosteroids
Topical corticosteroid preparations are often used for the treatment of seborrheic dermatitis. This treatment may also serve to limit the degree of hypo- or hyper-pigmentation that often occurs in brown skin. The corticosteroid preparation may be formulated as an ointment, oil, lotion or foam which seem to be best suited for patients with brown skin. A recent study demonstrated that a foam formulation of corticosteroids (Olux) applied to African Americans with seborrheic dermatitis was effective, well tolerated and did not interfere with the hair style of the subjects who used it. For individuals with thick flakes in the scalp, a corticosteroid oil formulation may be applied to the scalp flakes, left on overnight and washed out the next morning. As the oil is washed out, so too are the flakes or scales. With topical corticosteroids, long term use should be avoided, so that potential side effects such as thinning of the skin and blood vessel growth are prevented.

Topical anti-fungal agents
Several antifungal agents have been used in the treatment of seborrheic dermatitis. These include zinc pyrithione, miconazole, ketoconazole, fluconazole, and ciclopirox. The antifungal preparations do not carry the risks of the topical corticosteroid preparations. Presumably, the efficacy of the antifungal preparations in seborrheic dermatitis is related to the role of Malassezia yeast as a causative agent in the disease. Antifungal agents significantly decrease the number of Malassezia yeast in seborrheic dermatitis and improve the symptoms and appearance of the disorder.

Topical immunomodulators
Topical tacrolimus and pimecrolimus have been reported to possess antifungal activity as well. These agents are increasing being used for the treatment of seborrheic dermatitis although they are not specifically approved by the FDA for this indication. As with the topical antifungal preparations, the use of these agents avoids the potential side effects associated with topical corticosteroids. A study of 0.1% tacrolimus ointment in patients with seborrheic dermatitis demonstrated a 70% or greater improvement of the seborrheic dermatitis.

Bottom Line
Seborrheic dermatitis is a common disease in people with skin of color. In addition to the characteristic flaking and scaling of the face and scalp, hypo- and hyper-pigmentation are common. Treatment may involve both shampoos and topical products. It is important to avoid products that dry the hair. Additionally, the long term use of cortisone containing products should be avoided.