Interventions for infantile seborrheic dermatitis (including cradle cap)

Infantile seborrheic dermatitis (ISD), a benign, inflammatory skin condition, features an erythematous rash with greasy scaling and is reported in approximately 70% of infants by three months of age.

It is frequently managed using Baby shampoos, emollients, antifungals, and topical steroids; however, a uniform treatment recommendation still needs to be made. A 2019 Cochrane systematic review, "Interventions for infantile seborrhoeic dermatitis (including cradle cap)," provides a comprehensive assessment of randomized controlled trials (RCTs) for ISD interventions.

The review included 297 children (ages up to 24 months) from 6 RCTs diagnosed by a health care provider with ISD or cradle cap. Participants were primarily <7 months of age. The study looked for changes in ISD severity from baseline and the development of adverse effects or treatment intolerance. It also recorded Parent-reported quality-of-life improvements.

2 RCTs compared oral biotin with a placebo, and 1 study reported differences in rash duration, while the other suggested similar outcomes among comparison groups (which also used topical steroids). Two other RCTs examined proprietary products against placebo and reported an equal reduction in rash severity with Promiseb nonsteroidal cream (96%) and placebo (92%); higher decreases in the severity score with lactamide monoethanolamine gel plus shampoo than the shampoo alone. Lastly, 2 RCTs compared topical steroids with other products and found equal effectiveness of hydrocortisone 1% lotion and licochalcone 0.025% lotion. The studies found a similar reduction in the affected body surface area with both flumethasone pivalate 0.02% ointment (9%) and eosin 2% aqueous solution (7%). All around, the certainty of the evidence was very low. 

A recent open-label trial including ten infants has described an improvement of symptoms and reduction in the growth of contributing pathogens with a topical gel cream containing antifungal (piroctone olamine, Biosaccharide Gum-2), antiinflammatory (stearyl glycyrrhetinate), and antiseborrheic (zinc l-pyrrolidone carboxylate) ingredients.

Fungal density may describe a vital hallmark of seborrheic dermatitis; thus, targeting evidence-based research and practicing dermatologists' efforts toward antifungal shampoos may be beneficial.

Despite the self-limiting nature of ISD, it can be quite distressing to parents. This systematic review did not find conclusive evidence for the superiority of any specific treatment. Still, it delivers support for the successful use of emollients and shampoos and solace that expensive treatments are unnecessary. Furthermore, it encourages the avoidance of harmful treatments, like salicylic acid, that may be toxic when applied in high dosages.

Hassan S, Szeto MD, Sivesind TE, et al. From the Cochrane Library: Interventions for infantile seborrheic dermatitis (including cradle cap). JAAD online. 2022;86(2): E87-E88. DOI:https://doi.org/10.1016/j.jaad.2021.09.031