Yellow scalp patches with mild scaling - Clinical Advisor

Yellow scalp patches with mild scaling

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  • Seborrheic dermatitis_0414 Derm Clinic 2

A male infant, aged 12 weeks, developed scaly patches and dandruff on his scalp. The condition did not seem bothersome to the child, but his mother expressed cosmetic concerns. The patient was born at full term via uncomplicated caesarean section due to failure of labor to progress and was discharged home at age 4 days without complication. He was otherwise healthy and up to date on recommended vaccinations.

The patient was exclusively breastfed and given a daily dose of a multivitamin with vitamin D. There was no family history of skin disease. Physical exam revealed lightly adherent yellow scales on the vertex of the scalp and mild scaling of the forehead and glabella.



HOW TO TAKE THE POST-TEST: This Clinical Advisor CME activity consists of 3 articles. To obtain credit, you must also read Excoriations on extensor surfaces and Yellow scalp patches with mild scaling. Then take the post-test here .

Seborrheic dermatitis is a very common inflammatory skin condition among infants and children. When it affects the scalp it is commonly referred to as "cradle cap." Infantile seborrheic dermatitis causes flaking and thick yellow, white, or brown greasy patches to...

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Seborrheic dermatitis is a very common inflammatory skin condition among infants and children. When it affects the scalp it is commonly referred to as “cradle cap.”

Infantile seborrheic dermatitis causes flaking and thick yellow, white, or brown greasy patches to appear on the scalp and other sebaceous-gland-rich areas of the skin, such as the eyebrows, eyelids, ears, nasal creases, base of neck, and intertriginous areas. The scaling predominates on the scalp,1 usually appears in a symmetric distribution, and may be accompanied by a background of erythema.

Erythema tends to predominate in the flexural folds and intertriginous areas.1 Seborrheic dermatitis frequently spreads to the diaper area and should be considered in the evaluation of diaper dermatitis.2

Although the exact cause of seborrheic dermatitis is unknown, overproduction of sebum in the sebaceous glands and hair follicles and overproduction of the lipophilic yeast Malassezia furfur (previously known as Pityrosporum ovale) are thought to be involved.3 The resulting scale is accumulated epithelial debris that is adherent to the scalp.4 In addition, maternal hormone stimulation and genetic factors are thought to influence infantile seborrheic dermatitis. 


Risk factors that can cause and/or aggravate seborrheic dermatitis include temperature extremes, infrequent shampooing or soaping, use of lotions containing alcohol, and immunodeficiency. Unlike adult seborrheic dermatitis, infantile seborrheic dermatitis usually does not cause itching.

The condition typically appears between the second and tenth week of life, peaks in incidence at age 3 months, and resolves spontaneously by age 8 to 12 months. Seborrheic dermatitis will likely not reappear until after puberty.


Although seborrheic dermatitis of the scalp can be easily diagnosed, when it involves the skin the condition is often confused with atopic dermatitis.5 Age at onset and the presence or absence of pruritus can help distinguish between the two conditions.2

Seborrheic dermatitis usually begins in the first month of life, and pruritus is uncommon; atopic dermatitis typically begins after age 3 months, and pruritus is ubiquitous. Scales of seborrheic dermatitis appear more greasy and moist whereas atopic dermatitis is dryer and rougher. Occasionally, the two conditions can occur simultaneously or even consecutively.

Other less common conditions that may mimic seborrheic dermatitis include psoriasis, Langerhans cell histiocytosis, and Leiner disease (a group of nutritional and immunologic disorders). These should be considered in cases that are resistant to standard antiseborrheic treatments. Generalized seborrheic dermatitis accompanied by failure to thrive and diarrhea should prompt an evaluation for immunodeficiency.1

Infantile seborrheic dermatitis is usually self-limited and resolves within several weeks to several months.5 Although no treatment is necessary, and watchful waiting is appropriate, many parents will request recommendations to treat the scaling on the scalp. Daily shampooing with a gentle baby shampoo can be followed by the use of a soft brush to remove the scales. Alternatively, a fine-tooth comb can be used.

If the scales are thick and more adherent, parents can apply an emollient—such as mineral oil, baby oil, or white petrolatum—overnight to soften the scale. In the morning a soft brush can be used to massage and loosen the scales. Shampooing with a baby shampoo afterwards will help remove the scales. Soaking the scalp overnight with vegetable oil and then shampooing in the morning has also proven effective.5

For more severe cases of infantile seborrheic dermatitis that have an inflammatory component, a mild cortisone cream can be prescribed in conjunction with the use of a baby shampoo. Antiseborrheic shampoos, such as ketoconazole (Nizoral Shampoo), are beneficial in resistant cases but are often irritating, and use in infants should be avoided if possible.6 Parents should be cautioned not to use shampoos containing salicylic acid, sulfur, or selenium sulfide, as these can be toxic to infants if absorbed.


Seborrhea of the skin in infants can be treated with a topical antifungal cream applied once or twice daily. Alternatively, a low-strength hydrocortisone cream can be used sparingly. If the diaper area is involved, care should be taken to rule out secondary infections with bacteria or candida. If necessary, a culture should be taken and topical antibacterial or anticandidal creams should be prescribed as indicated. 


The mother in this case was counseled regarding the benign and self-resolving nature of the condition and educated on recommended methods to remove the scalp scales. Several weeks later, she reported a significant improvement in the quantity and thickness of the scales but noted that the condition had not yet completely resolved.

Esther Stern, NP-C, is a family nurse practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J.




HOW TO TAKE THE POST-TEST: This Clinical Advisor CME activity consists of 3 articles. To obtain credit, you must also read Excoriations on extensor surfaces and Yellow scalp patches with mild scaling. Then take the post-test here .


References


  1. Janniger CK. Infantile seborrheic dermatitis: an approach to cradle cap. Cutis. 1993;51:233-235.

  2. Williams ML. Differential diagnosis of seborrheic dermatitis. Pediatr Rev. 1986;7:204-211.

  3. Tollesson A, Frithz A, Stenlund K. Malassezia furfur in infantile seborrheic dermatitis. Pediatr Dermatol. 1997;14:423-425.

  4. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, Pa.: Saunders Elsevier; 2011:188-189.

  5. O’Connor NR, McLaughlin MR, Ham P. Newborn skin: Part I. Common rashes. Am Fam Physician. 2008;77:47-52. Available at www.aafp.org/afp/2008/0101/p47.html.

  6. Paller AS, Mancini AJ. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 4th ed. Philadelphia, Pa.: Saunders Elsevier; 2011:56-57.

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