Day: January 17, 2006

What are the Treatments for Persistant Cradle Cap?

Patient Presentation
A 2-year-old male came to clinic for his health maintenance examination. His mother has noticed that he still has cradle cap. She has tried baby shampoo, selenium sulfide shampoo, tar shampoos and mineral oil with scraping by a toothbrush.
These treatments slightly improve the problem but it continues.
The pertinent physical exam reveals a healthy toddler with some waxy, yellow, thick scale on the center of the scalp. The affected area is about 2 centimeters in diameter and is non-erythematous.
The diagnosis of continued seborrheic dermatitis was made. He was referred to dermatology who recommended a short course of topical steroids to decrease the scale. Once the scale was controlled alternating use of baby shampoo and salicylic acid shampoo was recommended.
If the scale returned, a short course topical steroids were recommended for control.
The patient’s clinical course showed no scale after 3 weeks of daily topical steroid. The scale is well controlled with alternating baby and tar shampoos.

Discussion
Seborrheic Dermatitis or seborrhea is a scaly, crusty eruption usually of the face, scalp, post auricular, presternal and intertriginous areas of the skin.
It commonly worsens with changes in humidity, seasons, or trauma. The cause is linked to Malassezia organisms and an abnormal immunological response with activated complement levels.
It commonly occurs in the first few weeks of infancy and generally clears by 8-12 months of age. It can recur during puberty and adolescense.
Cradle cap or infantile seborrheic dermatitis often occurs on the scalp and diaper area, but can spread to the face and back of the head. It has scales that are greasy, yellowish and thick.
It is different from seborrheic dermatitis of adolescents and adults as it lacks the presence of follicular lesions.
It is not pruritic and does not have the characteristics of atopic dermatitis.

Learning Point
The prognosis even without treatment is good as most cases of infantile seborrheic dermatitis clear within weeks. Complications include secondary bacterial or candidal infections.

Treatment for infantile seborrhea includes:

  • Anti-seborrheic shampoos including alternating tar, salicyclic acid, zinc or selenium shampoos
  • Loosening of the scale by mineral oil or other similar oil with scrubbing several hours later.
  • Topical corticosteroids – low to medium potency, with or without sulfur or salicyclic acid

Treatment for adolescent seborrhea includes:

  • Anti-seborrheic shampoos
  • Calcineurin inhibitors – pimecrolimus, tacrolimus
  • Topical corticosteroids
  • Antifungal medication – systemic medication may be helpful with recalcitrant cases

Treatment for blepharitis (i.e. inflammation of the eyelids) includes:

  • Warm water compresses
  • Dilute baby shampoo or other non-irritating shampoo
  • Topical antifungal medications are controversial because of the location

Questions for Further Discussion
1. How does seborrhea differ from psoriasis?
2. Is seborrhea related to atopic dermatitis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MEDLINEplus for this topic: Dermatitis

To view current news articles on this topic check Google News.

Hurwitz S. Clinical Pediatric Dermatology. 2nd Edit. WB Saunders Co. Philadelphia PA. 1993;62-63.

Selden S. Seborrheic Dermatitis. eMedicine.
Available from the Internet at http://www.emedicine.com/derm/topic396.htm (rev. 9/13/05, cited 11/23/05).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    9. Patient-focused case is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    January 17, 2006