Navigating SD Challenges: Expert Treatment Strategies

Transcript

Linda Stein Gold, MD: Shawn, I’m sure by the time somebody comes to you, they’ve already gone to their local CVS or Target. They’ve tried some of the over-the-counter products. How do you approach these patients when they walk in? And if I come in and I say, “Well, I used the over-the-counter products. I’m not getting the results,” How do you approach that patient? Where do you start?

Shawn Kwatra, MD: That’s a great question. Neal brought up a great point about the immune signatures in seborrheic dermatitis. And one thing that I’ve noticed is there’s a lot of heterogeneity in how patients present. James is talking about the hypopigmented areas that we see in skin of color patients. Or you can see bright erythema, scaling, and intense itch. So, actually, that’s a microcosm of different immune axes also being involved. We know that Th1 activity is important. You have some forms of seborrheic dermatitis that are very scaly, can even be called sebo-psoriasis. And you know you may have a little bit more Th17. Then you have some forms that are really itchy, and you think Th2. So, I use that when I’m treating. If it’s on their face, if it’s really itchy, I’ll often times give a topical steroid, very low potency, and hope that they do not use it chronically, every day. I’ll also use the topical calcineurin inhibitor if needed. I think many of us probably use the antifungal washes, ketoconazole or ciclopirox. I’ll tell you what though, in the scalp, it can be very damaging, as James mentioned, in skin of color patients. I have so many African American female [patients] who’ve said they can’t tolerate ketoconazole.

Linda Stein Gold, MD: It’s very difficult.

Shawn Kwatra, MD: It’s so dry. It’s such a problem.

Neal Bhatia, MD: It’s funny because you mentioned ciclopirox, it probably had the best activity against ptero-sporin species than the other, especially the azoles. And yet, we don’t find it anymore. It’s hard to get prescription ciclopirox, and all we get are generic substitutes for all the azoles.

Adelaide Hebert, MD: And I’ll mention too, in terms of pediatric care, we see some parents that are so vigorous. They actually have the child’s hair coming off and the scalp bleeding. So overtreatment is problematic even within the pediatric realm. So we have to keep counseling, and I agree with the leaving the shampoo on. If we have a medicated shampoo, we really need to go down into the follicular level. We give our patients and parents a handout with the chemical formulations listed in all the possible shampoos in that chemical group, so that they can pick and choose. And we also want to rotate these shampoos because of the issue of tachyphylaxis, where after you use the shampoo for a while, it won’t work as well anymore. It’s not like antibiotic resistance, but it is an important teaching moment so that they don’t think they have to keep using the same shampoo forever, and they’ll feel disappointment when it no longer gives them the results that they had hoped to have as their outcome.

Linda Stein Gold, MD: That’s an important point. And given the fact that this is often on sensitive areas, including the face and around the mouth, James, do you go to the nonapproved topical calcineurin inhibitors? I know they can sting and burn, and this is a condition where they’re already a little bit sensitive. What’s your thought on that, or do you stick with a steroid or an antifungal?

James Song, MD: That’s a great question, Linda. I would say that for a lot of our topical calcineurin inhibitors, they do have the burning and stinging problem, and the vehicle is something that left to be desired. Oftentimes it’s greasier, especially if you’re applying it to a hair-bearing area. It’s harder to put on. So I generally do stick with more topical cortical steroids and azoles in general. I love what’s already been said, but sometimes, when you have really severe seborrheic dermatitis, I may have to reach for a systemic agent as well. I don’t do it all that often, but especially if it’s diffusely on the scalp and you’re starting to get some body areas, even systemic azoles, like fluconazole, just doing a couple courses of that. There are some studies looking at very low-dose isotretinoin. That also has been shown to actually help as well. I don’t do it all the time, but for a recalcitrate seborrheic dermatitis, that’s something I will reach for.

Linda Stein Gold, MD: And you realize that this is something that’s impacting this patient’s, not just their overall quality of life, but their work, their relationships. I think we really underappreciate [that].

Neal Bhatia, MD: And part of that goes to what else is lying under the hood. You talk about patients with HIV, anyone with debilitating neurologic disorders, dementia, Parkinson [disease], what have you, then you’re dealing with a whole different approach, on top of the fact that your adherence levels are going to be small if they don’t have the wherewithal to apply everything, or if they’re institutionalized, then you’re even in bigger trouble.

Adelaide Hebert, MD: One other key point that I make, if I happen to be using a ketoconazole cream formulation, I tell the parents it comes in handy to have it at home for diaper rash, just generic diaper rash, as well, if that’s caused by Candida. So that’s a good selling point. They like to have that product around, and they will use it on an as-needed basis. They understand treating diaper dermatitis, pure diaper dermatitis, not seborrheic dermatitis but regular diaper dermatitis with ketoconazole if it’s due to a yeast, and they know that it’s intermittent use. So that is a reinforcement that I can give with another example with which they’re already familiar.

Linda Stein Gold, MD: So it sounds like we have kind of an unmet need. We talk about what’s FDA approved—well, not a whole lot. But what research have we been doing? For years and years we’ve all been doing research for pretty much our careers, and we haven’t really been looking at seborrheic dermatitis front and center. And so, it’s kind of time for a change.

Transcript was AI-generated and edited for clarity.