Topical antifungals for seborrhoeic dermatitis

Abstract

BackgroundSeborrhoeic dermatitis is a chronic inflammatory skin condition that is distributed worldwide. It commonly affects the scalp, face and flexures of the body. Treatment options include antifungal drugs, steroids, calcineurin inhibitors, keratolytic agents and phototherapy.ObjectivesTo assess the effects of antifungal agents for seborrhoeic dermatitis of the face and scalp in adolescents and adults.A secondary objective is to assess whether the same interventions are effective in the management of seborrhoeic dermatitis in patients with HIV/AIDS.Search methodsWe searched the following databases up to December 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 11), MEDLINE (from 1946), EMBASE (from 1974) and Latin American Caribbean Health Sciences Literature (LILACS) (from 1982). We also searched trials registries and checked the bibliographies of published studies for further trials.Selection criteriaRandomised controlled trials of topical antifungals used for treatment of seborrhoeic dermatitis in adolescents and adults, with primary outcome measures of complete clearance of symptoms and improved quality of life.Data collection and analysisReview author pairs independently assessed eligibility for inclusion, extracted study data and assessed risk of bias of included studies. We performed fixed-effect meta-analysis for studies with low statistical heterogeneity and used a random-effects model when heterogeneity was high.Main resultsWe included 51 studies with 9052 participants. Of these, 45 trials assessed treatment outcomes at five weeks or less after commencement of treatment, and six trials assessed outcomes over a longer time frame. We believe that 24 trials had some form of conflict of interest, such as funding by pharmaceutical companies.Among the included studies were 12 ketoconazole trials (N = 3253), 11 ciclopirox trials (N = 3029), two lithium trials (N = 141), two bifonazole trials (N = 136) and one clotrimazole trial (N = 126) that compared the effectiveness of these treatments versus placebo or vehicle. Nine ketoconazole trials (N = 632) and one miconazole trial (N = 47) compared these treatments versus steroids. Fourteen studies (N = 1541) compared one antifungal versus another or compared different doses or schedules of administration of the same agent versus one another.KetoconazoleTopical ketoconazole 2% treatment showed a 31% lower risk of failed clearance of rashes compared with placebo (risk ratio (RR) 0.69, 95% confidence interval (CI) 0.59 to 0.81, eight studies, low-quality evidence) at four weeks of follow-up, but the effect on side effects was uncertain because evidence was of very low quality (RR 0.97, 95% CI 0.58 to 1.64, six studies); heterogeneity between studies was substantial (I² = 74%). The median proportion of those who did not have clearance in the placebo groups was 69%.Ketoconazole treatment resulted in a remission rate similar to that of steroids (RR 1.17, 95% CI 0.95 to 1.44, six studies, low-...

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“…Treatment for SD should aim for not just achieving remission of lesions but also to eliminate itching and burning sensation and prevent recurrence of the disease [6]. A variety of treatment options are available for the treatment of SD.…”

“…There have been reports of successful use of tacrolimus as well [9]. Behavioral modifications such as frequent skin cleansing, resolute commitment to personal hygiene and frequent outdoor recreation, especially in summer, have been found to lessen the symptoms [6]. Other therapeutic modalities include salicylic acid, zinc pyrithione and coal tar, which are applied topically and function to soften and remove the thick hardened crusts that sometimes occur in SD.…”

“…Other therapeutic modalities include salicylic acid, zinc pyrithione and coal tar, which are applied topically and function to soften and remove the thick hardened crusts that sometimes occur in SD. Oral therapies like antifungals and retinoids or physical therapies like PUVA may be beneficial when multiple anatomic sites are involved, for patients who are unresponsive to traditional topical therapies and/or for those with severe SD [6,8]. In this article, the authors have focused on topical antifungal agents with published reports of efficacy in SD, which are available in various formulations such as ointments, creams, gels and shampoos in the market.…”

“…Other such outcome assessment measures employed by various studies establishing the efficacy of a drug in SD mainly include total clearance of lesions at the end of treatment phase/maintenance phase, mean change in symptom scores, i.e. erythema score, scaling score & pruritus score and patient assessment methods (usually visual analogue score method) [6].…”

“…Various studies conducted on ketoconazole have used it in varying doses. The most frequent dose was 2% twice daily every day over face and 2% twice a week over scalp [6]. …”