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Topical anti-inflammatory agents for seborrhoeic dermatitis of the face or scalp

  1. Helena Kastarinen1,*,
  2. Tuija Oksanen1,
  3. Enembe O Okokon2,
  4. Vesa V Kiviniemi3,
  5. Kristiina Airola4,
  6. Johanna Jyrkkä1,
  7. Tuomas Oravilahti1,
  8. Piia K Rannanheimo1,
  9. Jos H Verbeek5

Editorial Group: Cochrane Skin Group

Published Online: 19 MAY 2014

Assessed as up-to-date: 18 SEP 2013

DOI: 10.1002/14651858.CD009446.pub2


How to Cite

Kastarinen H, Oksanen T, Okokon EO, Kiviniemi VV, Airola K, Jyrkkä J, Oravilahti T, Rannanheimo PK, Verbeek JH. Topical anti-inflammatory agents for seborrhoeic dermatitis of the face or scalp. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD009446. DOI: 10.1002/14651858.CD009446.pub2.

Author Information

  1. 1

    Finnish Medicines Agency Fimea, Assessment of Pharmacotherapies, Fimea, Finland

  2. 2

    University of Calabar Teaching Hospital, Department of Community Medicine, Calabar, Cross River State, Nigeria

  3. 3

    Finnish Medicines Agency, Assessment of Pharmacotherapies, Kuopio, Finland

  4. 4

    Finnish Medicines Agency Fimea, Assessment of Medicinal Products, Fimea, Finland

  5. 5

    Finnish Institute of Occupational Health, Cochrane Occupational Safety and Health Review Group, Kuopio, Finland

*Helena Kastarinen, Assessment of Pharmacotherapies, Finnish Medicines Agency Fimea, P.O. Box 55, Fimea, 00034, Finland. helena.kastarinen@fimnet.fi.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 19 MAY 2014

SEARCH

 

Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes

 
Summary of findings for the main comparison. Calcineurin inhibitor compared with steroid for seborrhoeic dermatitis of the scalp or face

Steroid compared with calcineurin inhibitor for seborrhoeic dermatitis of the scalp or face

Patient or population: people with seborrhoeic dermatitis
Settings: community setting implied from context but not stated
Intervention: steroid
Comparison: calcineurin inhibitor

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Calcineurin inhibitorSteroid

Total clearance (at 4 weeks or less)
Investigator's assessment
Follow up: ≦ 2 weeks
839 per 1000906 per 1000
(738 to 1000)
RR 1.08
(0.88 to 1.32)
60
(2 studies)
⊕⊕⊝⊝
low¹,²
-

*The basis for the assumed risk is the risk in the control groups of the relevant trials. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 ¹Participants were not blinded.
²Small number of participants in studies.

 Summary of findings 2 Steroid compared with azole for seborrhoeic dermatitis of the scalp or face

 Summary of findings 3 Strong steroid (class III or IV) compared with mild steroid (class I or II) for seborrhoeic dermatitis of the scalp or face

 Summary of findings 4 Lithium compared with azole for seborrhoeic dermatitis of the scalp or face

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes

Seborrhoeic dermatitis or eczema is a chronic inflammatory skin disorder primarily affecting areas rich in sebaceous glands (Kim 2010). Such areas include, for example, skin of the scalp, face, chest, and intertriginous areas (areas where folds of skin are touching each other, such as the armpits, groin, and abdominal folds). These areas are liable to irritation from sweating and infection (Naldi 2009). Typical symptoms of the disease are scaling of the skin and erythematous (reddish) patches (Schwartz 2006).

 

Description of the condition

The specific cause of seborrhoeic dermatitis (SeD) is not known in detail. Despite its name and affected areas, this disease is not always associated with excessive sebum secretion (Burton 1983). It has been suggested that many endogenous and exogenous factors are associated with the course and severity of this disorder. These include hormonal factors; comorbidities (associated diseases); individual immunological features; and nutritional, environmental, and lifestyle factors (Gupta 2004; Schwartz 2006), but the mechanism of action of each of these factors has not been determined. A causative role has been suggested for Malassezia yeasts because SeD responds to antifungal treatments when a concurrent decrease of the number of the yeasts on the skin is seen (Gupta 2004). However, the overall evidence is still somewhat unclear.

The diagnosis of this disease is largely clinical and based on affected areas and the type of rash. Ill-defined erythematous patches with fine scaling on the sides of the nose, eyebrows, and scalp are seen most often in adult patients. Pruritus (itch) is often present in an affected scalp (Del Rosso 2011). In dark-skinned people, SeD can present as postinflammatory changes, such as hypopigmentation (Halder 2003). A skin biopsy is rarely needed for diagnosis, but it can be useful for excluding other less common conditions, such as lupus (Naldi 2009; Schwartz 2006). Dandruff is a commonly used term for any scalp condition that produces fine scales, but it has also been used in the context of mild SeD (Naldi 2009; Schwartz 2006). The disease has a chronic nature with occasional relapses. The severity of SeD varies from mild flaking to severe oily scaling. The distribution of lesions is generally symmetrical (Gupta 2004). Although the disease affects the skin of the scalp, it does not normally cause baldness.

Seborrhoeic dermatitis is a fairly common skin disorder. The prevalence is not known precisely as there are no validated criteria for diagnosis of the condition (Naldi 2009). An infantile form (cradle cap) has been reported to affect as many as 70% of newborns during the first three months of life, but this quickly resolves (Foley 2003). So, the overall prevalence of seborrhoeic dermatitis is 10% in children five years of age or younger (Foley 2003). In the adult population, prevalence is between 1% to 3%, and occurrence is more common in adolescents and young adults than those in middle age (Gupta 2004). The incidence increases again in people over 50 years of age (Gupta 2004). Seborrhoeic dermatitis affects men more frequently than women, and some diseases, such as Parkinson's disease and HIV (human immunodeficiency virus)/AIDS, are known to increase the risk of the disease (Naldi 2009).

 

Description of the intervention

The standard treatments for seborrhoeic dermatitis include topical anti-inflammatory (immunomodulatory) agents, such as corticosteroids and calcineurin inhibitors, to reduce inflammation; topical antifungals, such as azoles, ciclopirox olamine, and zinc pyrithione, to reduce Malassezia; and topical keratolytic agents, such as salicylic acid, tar, selenium sulphide, and zinc pyrithione, to soften and remove thick hardened crusts. Many agents have multiple mechanisms of action, and in some, the exact mechanism is not known (Gupta 2004; Naldi 2009; Schwartz 2006).

 

How the intervention might work

Topical corticosteroids (e.g. hydrocortisone, betamethasone, clobetasol, and desonide) have traditionally been used in the treatment of SeD. They reduce inflammation and relieve erythema and itching. Calcineurin inhibitors (e.g. pimecrolimus and tacrolimus) have also been used for their anti-inflammatory effects. It has been suggested that lithium salts, lithium succinate (often in combination with zinc sulphate), and lithium gluconate have anti-inflammatory effects, but they may also have antifungal properties (Gupta 2004; Naldi 2009; Schwartz 2006).

 

Why it is important to do this review

Seborrhoeic dermatitis is a fairly common skin disorder that affects a considerable number of children and adults. There are many available treatment options, but it is unclear which should be preferred. It is important to evaluate the efficacy of these options in order to improve the outcome of the therapy. This review is one of two Cochrane systematic reviews on this topic and will focus on treatment options with an established anti-inflammatory mechanism. The other Cochrane review is focused on drugs with an antifungal mechanism (Okokon 2011).

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes

To assess the effects of topical pharmacological interventions with established anti-inflammatory action for seborrhoeic dermatitis occurring in adolescents and adults.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
 

Criteria for considering studies for this review

 

Types of studies

We included randomised controlled trials and cross-over randomised controlled trials (including within-patient studies).

We excluded cluster randomised trials.

 

Types of participants

We included studies of adults or adolescents (> 16 years) with diagnosed seborrhoeic dermatitis of the scalp or face. At least 75% of the study participants had to be over 10 years of age to fulfil the age criterion.

We excluded studies of people having other skin diseases or seborrhoeic dermatitis occurring solely in areas other than the scalp or face.

 

Types of interventions

We included the following topically administered drugs with an established anti-inflammatory mechanism of action: corticosteroids and calcineurin inhibitors. We also included lithium salts in the review as it has been suggested that their effect is based on anti-inflammatory properties.

We excluded studies in which the anti-inflammatory intervention had been combined with a non-anti-inflammatory agent in preparation. We examined all clinically relevant comparisons between treatments.

 

Types of outcome measures

 

Primary outcomes

  1. Percentage of treated persons with total resolution of symptoms as evaluated by the outcome assessor (total clearance).
  2. Disease severity scores for scaling, pruritus, or erythema at the end of treatment as evaluated by participant self-report, outcome assessor, or both.
  3. Percentage of persons treated who develop side-effects or intolerance to treatment.

 

Secondary outcomes

  1. Improvement in quality of life.

 

Timing of outcomes

We defined the timing of outcomes using the following categories:

  1. When the treatment period lasted for four weeks or less, we defined these outcomes as short-term effects.
  2. When the treatment period lasted for more than four weeks, we defined these outcomes as long-term effects.

 

Search methods for identification of studies

We aimed to identify all relevant randomised controlled trials (RCTs) regardless of language or publication status (published, unpublished, in press, or in progress).

 

Electronic searches

We searched the following databases up to 18 September 2013:

  • the Cochrane Skin Group Specialised Register using the following terms: "seborrh* dermatitis" or "scalp dermatos*" or "scalp dermatitis" or "scalp eczema" or "cradle cap" or dandruff or malassezia or "seborrh* eczema";
  • the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library using the search strategy in Appendix 1;
  • MEDLINE via OVID (from 1946) using the strategy in Appendix 2;
  • Embase via OVID (from 1974) using the strategy in Appendix 3;
  • the Global Resource of EczemA Trials (GREAT, Centre of Evidence Based Dermatology, accessed at http://www.greatdatabase.org.uk on 18 September 2013) using the same search terms as for the Skin Group Specialised Register above; and
  • LILACS (Latin American and Caribbean Health Science Information database, from 1982) using the strategy in Appendix 4.

 

Trials databases

We searched the following trials registers on 22 October 2013, using the following search terms: seborrheic dermatitis or seborrhoeic or dandruff or cradle cap or malassezia or scalp dermatoses.

 

Searching other resources

 

References from included studies

We checked the bibliographies of included studies for further references to relevant trials.

 

Adverse effects

We did not perform a separate search for adverse effects of the target interventions. We examined data on adverse effects from the included studies we identified.

 

Data collection and analysis

 

Selection of studies

Three authors (TOk, HK, and JJ) independently identified relevant articles retrieved from the literature searches by assessing their titles and abstracts. Where we had differing views, we retained the article for full-text assessment.

The same three authors and one additional author (TOr) independently assessed the full-text papers using study eligibility forms in order to determine which studies satisfied the inclusion criteria. Where there were differing views that could not be resolved between the review authors, a third author (PP) made the decision of inclusion or exclusion.

 

Data extraction and management

The same authors (TOk, HK, and JJ) carried out data extraction independently using data extraction forms. A third researcher (PP) resolved discrepancies if consensus could not be found between the primary authors. TOk and HK managed the data including entering it into Review Manager (RevMan). HK checked the entered data for accuracy. We requested any further information needed from the original authors by email and included any relevant information obtained in this manner in the review.

 

Assessment of risk of bias in included studies

The assessment of the risk of bias included an evaluation of the following components for each included study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011):

(a) selection bias - we considered whether the methods of randomisation were adequate and whether the treatment allocation was concealed in the included studies. As there was some overlap between the clinical spectrum of seborrhoeic eczema and dandruff, we paid attention to the presence of the diagnosis of seborrhoeic dermatitis in participants and to the baseline severity of the disease in study groups;
(b) performance bias - we assessed whether the participants and the caregivers were blinded to the interventions and whether cointerventions and other treatments were similar in study groups;
(c) detection bias - we evaluated whether the outcome assessors were blinded to the interventions;
(d) attrition bias - we assessed whether the trial described dropout rates and whether they were acceptable, whether compliance was acceptable in all groups, and whether the study reports used intention-to-treat analysis (we used the number of randomised participants in our analyses, where available);
(e) reporting bias - we evaluated whether there were signs of selective reporting in the studies; and
(f) other bias - we evaluated whether there might have been other sources of bias, for example, relating to particular study designs.

We assessed the study quality without blinding to authorship or journal.

We have summarised the information in the 'Risk of bias' table for each included study.

 

Measures of treatment effect

For dichotomous outcomes, we expressed the combined estimate of effects as risk ratios (RR) and their 95% confidence intervals (Cl). For the main outcome (total clearance), we expressed summary estimates also as number needed to treat (NNT) for statistically significant findings, with a 95% CI and the baseline risk to which it applies.

For continuous outcomes, we used the mean difference with a 95% CI for summarising results. Where similar outcomes were measured differently across studies but measured the same concept, we used the standardised mean difference and a 95% confidence interval.

 

Unit of analysis issues

When there was intrapatient correlation in studies that had randomised body parts of the same participant and the study authors had not adjusted for this clustering effect, we did this adjustment according to the methods described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

We analysed studies with multiple treatment groups using pair-wise comparisons. We avoided counting the control group of multiple treatment studies twice, by dividing the number of control participants over the number of comparisons in the same meta-analysis, excluding the outcome of any adverse effects.

 

Dealing with missing data

We applied the intention-to-treat (ITT) principle by considering dropouts as non-responders (conservative approach). If data necessary for meta-analysis (such as standard deviations) were missing in the trial reports, we asked study authors for additional information. If they could not be reached, we calculated the necessary data from other statistics, if such information was available, or approximated them from information (e.g. graphics) given in the reports.

 

Assessment of heterogeneity

We assessed clinical heterogeneity by examining types of participants, interventions, and outcomes in each study. We assessed statistical heterogeneity using the I² statistic. We interpreted heterogeneity in effect estimates as considerable when the I² statistic was greater than 50%.

 

Assessment of reporting biases

We assessed reporting bias as within-study reporting bias (selective outcome reporting) and as publication bias. We did not perform funnel plot analyses as the number of studies was small in our meta-analyses. To avoid language bias, we imposed no language restrictions.

 

Data synthesis

For studies judged to be clinically and statistically homogenous with an I² statistic < 50%, we pooled the measures of treatment effect using their weighted average for the treatment effect (using a fixed-effect meta-analysis method, as implemented in Review Manager). For studies deemed to be heterogeneous (I² statistic ≥ 50%), we performed a random-effects meta-analysis. For studies with I² statistics more than 80%, we did not perform a meta-analysis, but described the results individually.

 

Subgroup analysis and investigation of heterogeneity

We planned to explore heterogeneity by examining age (less than 65 or over 65 years), gender (male or female), and dose (frequency) distributions of the studies. We aimed to conduct subgroup analyses if significant heterogeneity between the studies for the primary outcomes in a comparison appeared. The number of studies was small in most comparisons; therefore, performing subgroup analyses was not reasonable with the exception of comparison between mild and strong steroids.

 

Sensitivity analysis

We aimed to but did not perform sensitivity analyses to examine the effects of risk of bias as there were few studies in each comparison. Furthermore, the overall risk of bias was at least moderate in most studies.

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
 

Description of studies

 

Results of the search

The database searches yielded 1019 records. We identified a further seven records:

  • five from handsearching the references of our included studies;
  • one from a related Cochrane review (Okokon 2011); and
  • one published study from a trials register (Ortonne 2011).

We screened 1026 records, of which we excluded 912 based on the title and abstract or because they were duplicates.

We screened 114 full-text articles. We excluded 76 records (see the 'Characteristics of excluded studies' tables).

Altogether, we included 36 studies (see the 'Characteristics of included studies' tables). We assigned two studies to the Studies awaiting classification section on the grounds that it was unclear whether they measured the outcomes of interest.

We present our screening process in Figure 1.

 FigureFigure 1. Study flow diagram

 

Included studies

 

Study design

All 36 included studies, with 2706 participants, were reported as randomised controlled trials, with three comparing body parts.

 

Year of study

The 36 included studies were carried out between 1970 and 2012 with 13 studies before the year 1990, 10 studies between 1990 and 2000, and 13 studies after the year 2000.

 

Participants

In seven studies, a physician explicitly diagnosed participants with seborrhoeic dermatitis (SeD), and in 29 studies, this was unclear (implied from context but not clearly stated). The definition of SeD was given in one study only (Cicek 2009). The studied area was the scalp only in 16 reports; the face only in 10 reports; the face and scalp in one report; and the face, scalp, or both with other areas in seven reports. Two studies did not specify the affected and investigated areas, but it could be concluded that they included facial or scalp involvement based on the assessed body areas.

Six studies included participants under 18 years of age (from ages 12, 14, or 15 upwards). Four reports did not state the age of the participants. In three studies, there was an upper limit of age (65 years in two and 55 years in one study). All studies but one included both men and women (Langtry 1997 included only homosexual men with HIV). Frequent exclusion criteria were pregnancy, lactation state, other dermatoses or interventions, too severe or mild disease, or HIV. The older studies often did not report the exclusion criteria.

The number of participants in individual studies varied between 12 and 303, resulting in a median of 64.

 

Geography

The geographical variation of studies was as follows: USA (10 studies), France (four studies), Greece (four studies), Sweden (four studies), Turkey (three studies), Finland (two studies), UK (two studies), Iran (one study), Denmark (one study), Korea (one study), India (one study), Canada (one study), and Netherlands (one study). One study was multicentre (Belgium, France, Germany, Mexico, and South Korea).

 

Interventions

The included studies used the following drugs (doses and mode of delivery) for seborrhoeic dermatitis.

  • Mild steroids (class I or class II, classification according to the ATC (Anatomical Therapeutic Chemical) classification by the World Health Organization (WHO))

    • hydrocortisone (cream 1%, liniment 1%, lotion 0.1%, ointment 1.0%, and solution 1%)
    • alclometasone (ointment 0.05%)
    • desonide (cream 0.05%)

  • Strong steroids (class III or class IV, classification according to ATC classification by the WHO)

    • methylprednisolone (cream 1%)
    • betamethasone (lotion 0.1%, lotion 0.05%, cream 0.1%, and solution 1 mg/ml)
    • clobetasol (shampoo 0.05% and cream 0.05%)
    • amcinonide (lotion 0.1%)
    • mometasone (solution 0.1% or cream 0.1%)
    • fluocinolone acetonide (solution 0.01%, shampoo 0.01%)
  • Calcineurin inhibitors

    • pimecrolimus (cream 1%)
    • tacrolimus (ointment 0.1%)
  • Azoles

    • ketoconazole (cream 2%, foaming gel 2%, shampoo 2%, shampoo 1%, and hydrogel 20 mg/g)
    • metronidazole (gel 0.75%)
    • miconazole (base 2%)
  • Lithium (gluconate ointment 8% and succinate ointment 8%)
  • Zinc pyrithione (shampoo 1%)
  • Calcipotriol (solution 50 μg/ml)
  • Promiseb® (cream)
  • Placebo or propylene glycol

We decided to pool together all steroid studies as there were so many different steroidal compounds studied and often only one study on one compound. We also decided to pool together all calcineurin inhibitors and all azoles as the number of studies was limited. This enabled us to make the following direct comparisons.

  1. Steroids compared with placebo (six trials)
  2. Steroids compared with calcineurin inhibitors (five trials)
  3. Steroids compared with azoles (12 trials)
  4. Steroids compared with other compounds (calcipotriol, zinc pyrithione, Promiseb®) (three trials)
  5. Mild steroids compared with strong steroids (five trials)
  6. Calcineurin inhibitors compared with placebo (one trial)
  7. Calcineurin inhibitors compared with azoles (two trials)
  8. Calcineurin inhibitors compared with other compounds (zinc pyrithione) (one trial)
  9. Lithium salts compared with placebo (two trials)
  10. Lithium salts compared with azoles (one trial)

We also identified two studies comparing a mild steroid with another mild steroid (Cornell 1986; Cornell 1993) and one study comparing a strong steroid with another strong steroid (Cornell 1989). We do not display the results for these comparisons, however, as the focus of this review is to compare anti-inflammatory treatments with placebo and comparisons between different anti-inflammatory treatment classes.

We contacted three authors for additional data, which we received from two.

 

Outcomes

Twenty-three of the 36 included studies used total clearance as a measure of outcome. Resolution of symptoms was measured either on scale or as resolution of that specific symptom as follows: scaling in 19 studies, erythema in 17 studies, pruritus in 15 studies. The validation of the scales used was not reported in any of the articles. In four studies, adverse events were the only outcome we could use in this review (Cicek 2009; Ortonne 1992; Ortonne 2011). Seven studies (19%) did not report the side-effects.

 

Excluded studies

We excluded 76 studies. The most frequent reason for exclusion was that the intervention in the study was not anti-inflammatory or it was a combination of two drugs. Another common reason for excluding a study was that the proportion of people with SeD was unclear or that the proportion of them was too small. We identified two studies that did not report outcomes relevant for this review or did not report them in numerical form. We excluded them as they had no useful data to add to the analyses (Kim 2012; Marks 1974).

We present detailed reasons for exclusions in the 'Characteristics of excluded studies' tables.

 

Studies awaiting classification and ongoing studies

We assigned two studies to the Studies awaiting classification section as we had no evidence that they measured the outcomes of interest. We will reconsider these studies in the next update of the review. See the 'Characteristics of studies awaiting classification' tables for details. We identified seven studies from trials registers that are either ongoing or not yet published. See the 'Characteristics of ongoing studies' tables for details.

 

Risk of bias in included studies

We assessed the risk of bias in the included studies as described above (Assessment of risk of bias in included studies). The most frequent classification of risk of bias in studies was unclear. This was especially because of unclear reporting of methods, such as reporting studies to be double-blind without specifying who was blinded. Figure 2 displays the overall percentages of risk of bias for the studies included in the review. Figure 3 displays the risk of bias judged for each included study.

 FigureFigure 2. 'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies
 FigureFigure 3. 'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study

 

Allocation

Most reports classified selection bias as unclear. They often stated that participants were randomly allocated but did not report the methods of randomisation or allocation sequence concealment in detail. Twelve studies reported the generation of the randomisation sequence, and most commonly, it was computer-based. Only two studies described the allocation concealment method; otherwise, the studies did not mention it at all, and therefore we classified them as unclear risk.

 

Blinding

Most often the studies were reported to be double-blind, but it was not clear which two of the three parties (the participants, the caregivers, or the outcome assessors) were blinded. In these cases, we evaluated the risk of bias as unclear. Seven reports stated that the whole study was outcome assessor blinded. Six of the included studies were completely open-label or did not mention blinding, which we rated as at high risk of detection bias.

 

Incomplete outcome data

We evaluated attrition bias to be low in 23 of the studies. The reason we classified a study with a high risk for attrition bias was most often because of a considerable dropout rate (over 20%). We evaluated attrition bias to be unclear in eight studies when it was unclear whether the results given in percentages were calculated using the randomised or the completed participant numbers.

 

Selective reporting

We classified the risk for reporting bias as low in 29 of the studies. One study did not prespecify the outcomes in the report, but the outcomes reported were those commonly used in SeD studies. In seven studies, there was no mention of side-effects at all, which we consider a serious omission. However, we did not assess the lack of information concerning side-effects as a reporting bias unless the measurement of adverse effects was part of the predefined outcome measures, but had not been reported.

 

Other potential sources of bias

We sought other potential sources of bias. One study (Cicek 2009) evaluated both the efficacy outcome and side-effects using the same symptoms (erythema and pruritus were both an efficacy outcome and a side-effect); therefore, it was impossible for a reader to evaluate when or why these symptoms were classified as an outcome or a side-effect. Therefore, we classified the risk of bias as high for this trial. One study (Koc 2009) did not report the affected area (although we could conclude from the report that facial involvement was an inclusion criterion); therefore, we were not sure that the efficacy or the intervention on facial or scalp SeD was the same as reported in the article. We judged the risk of bias as low regarding this study. One study (Langtry 1997) only included male HIV participants, which may limit the ability to generalise the results into other populations. (We judged risk of bias as unclear.)

The most common circumstance in studies classified as having unclear risk was author affiliation to the pharmaceutical industry or interventions sponsored or provided by the pharmaceutical industry (N = 21 for studies having some kind of affiliations to the pharmaceutical industry). This classification was done categorically, and it does not imply that in the opinion of the review authors, these studies have increased risk of bias. In 13 studies, we were unable to identify other potential sources of bias, so we classed these at low risk of bias.

 

Similarity of study groups (selection bias)

Most of the included studies described adequately the similarity of study groups, and the risk of bias was low in 20 studies.

 

Effects of interventions

See:  Summary of findings for the main comparison Calcineurin inhibitor compared with steroid for seborrhoeic dermatitis of the scalp or face;  Summary of findings 2 Steroid compared with azole for seborrhoeic dermatitis of the scalp or face;  Summary of findings 3 Strong steroid (class III or IV) compared with mild steroid (class I or II) for seborrhoeic dermatitis of the scalp or face;  Summary of findings 4 Lithium compared with azole for seborrhoeic dermatitis of the scalp or face

We have addressed the comparisons under the following headings.

  • Steroids versus comparators

    • Steroids versus placebo
    • Steroids versus calcineurin inhibitors
    • Steroids versus azoles
    • Mild steroids versus strong steroids
    • Other comparisons for steroids

  • Calcineurin inhibitors versus comparators

    • Calcineurin inhibitors versus placebo
    • Calcineurin inhibitors versus azoles
    • Calcineurin inhibitors versus zinc pyrithione

  • Lithium versus comparators

    • Lithium salts versus placebo
    • Lithium salts versus azoles

For each of these comparisons, we addressed our prespecified outcomes. Our primary outcomes were as follows.

  1. Percentage of treated persons with total resolution of symptoms as evaluated by the outcome assessor (total clearance).
  2. Disease severity scores for scaling, pruritus, or erythema at the end of treatment as evaluated by participant self-report, outcome assessor, or both.
  3. Percentage of persons treated who develop side-effects or intolerance to treatment.

With regard to our primary outcome 'Total clearance', we considered this to be present where the terms "complete" or "total" resolution of symptoms or cure or clearance were used, whereas we did not accept as total clearance the term "excellent" without any definition of its meaning. Total clearance was the investigator's assessment unless otherwise stated. The included studies reported our other primary outcomes 'Disease severity' and 'Adverse events'.

None of the included studies assessed our secondary outcome 'Quality of life'.

 

Steroids versus comparators

We identified six studies comparing steroids with placebo or vehicle, five studies comparing steroids with calcineurin inhibitors, and 12 studies comparing steroids with azoles. Of these studies, one compared steroid with placebo and azole, one compared steroid with calcineurin inhibitor and azole, and one compared steroid with calcineurin inhibitor and zinc pyrithione. Additionally, we identified one study that compared steroid with Promiseb®, which is a non-steroidal compound, and one study that compared steroid with calcipotriol (vitamin C).

We performed subgroup analyses using the strength of the steroid compound as classification criterion. We classified class I and II steroids as mild steroids, and we classified class III and IV steroids as strong steroids. Five identified studies compared strong steroids with mild steroids. Furthermore, we identified two studies comparing a mild steroid with another mild steroid (Cornell 1986; Cornell 1993), and one study comparing a strong steroid with another strong steroid (Cornell 1989). We did not display the results for these three comparisons, as the focus of this review is to compare anti-inflammatory treatments with placebo and comparisons between different anti-inflammatory treatment classes. We also included analyses comparing mild steroids with strong steroids. We consider these comparisons to be most important from the clinical decision-making point of view.

 

Steroids versus placebo

In our analyses, steroids displayed a stronger effect on the studied outcomes than placebo with a comparable safety profile.

 
Total clearance (at four weeks or less of treatment)

Three studies, with a total of 303 participants, investigated this outcome. Participants achieved 'Total clearance' with steroids more often than with placebo (risk ratio (RR) 3.76, 95% confidence interval (CI) 1.22 to 11.56) when pooling steroids together ( Analysis 1.1) (number needed to treat (NNT) 4, 95% CI 3 to 6). Two studies not included in this meta-analysis (Harris 1972; Reygagne 2007;  Table 1) further supported this finding. However, there were indications that only a strong steroid is more effective than placebo (RR 5.92, 95% CI 0.99 to 35.52) in  Analysis 1.1.

 
Total clearance (at four weeks or more)

One study with 43 participants examined the effect of a strong steroid on total clearance compared with placebo and found that participants achieved total clearance more often with the steroid than with placebo (RR 2.24, 95% CI 1.10 to 4.56) ( Analysis 1.2) (NNT 3, 95% 1 to 11).

 
Erythema (at four weeks or less of treatment)

One study with 134 participants examined the mean change in erythema scores. There was a greater reduction in erythema score with a strong steroid (in favour of steroid) than with placebo (mean difference (MD) 0.53, 95% CI 0.27 to 0.79) ( Analysis 1.3).

This finding is furthermore supported by another study (44 participants) (Reygagne 2007;  Table 1). A study with 98 participants examined the level of erythema scores at the end of treatment and found that with strong steroid the erythema score was lower (in favour of steroid) when compared with placebo (MD -0.79, 95% CI -1.07 to -0.51) ( Analysis 1.4).

 
Scaling (at four weeks or less of treatment)

One study with 136 participants examined the mean change in scaling scores. There was a greater reduction in scaling score with strong steroid (in favour of steroid) than with placebo (MD 0.77, 95% CI 0.49 to 1.05) ( Analysis 1.5). Another study with 98 participants reported the level of scaling scores at the end of treatment, and here also, a strong steroid was more effective than placebo because the scaling score was lower with steroid (MD -0.80, 95% CI -1.10 to -0.50) ( Analysis 1.6).

One study with 44 participants (Reygagne 2007;  Table 1) further supported this finding.

 
Pruritus (at four weeks or less of treatment)

One study with 116 participants examined the mean change in pruritus scores and found that there were no statistically significant differences between a strong steroid and placebo (MD 0.27, 95% CI -0.04 to 0.58) ( Analysis 1.7). Another study with 98 participants reported the level of pruritus scores at the end of treatment. In this study, a strong steroid proved to be more effective than placebo (MD -0.41, 95% CI -0.69 to -0.13) ( Analysis 1.8).

Another study with 44 participants found a strong steroid to be more effective in this outcome when compared with placebo (Reygagne 2007;  Table 1).

 
Any adverse effects

One study compared a mild steroid and placebo, and three studies compared a strong steroid and placebo. As a whole, there were 606 participants in these trials. We found no statistically significant differences between steroid treatment and placebo regardless of the strength of the steroid (pooled RR 0.89, 95% CI 0.29 to 2.72) ( Analysis 1.9). One study with 44 participants (Reygagne 2007;  Table 1) supported this finding. We could not use in meta-analysis one study with 100 randomised participants, which reported that there were no adverse effects (Ramirez 1993), as the effect estimate was inestimable.

The most commonly reported adverse effects were burning and itching in both steroid and placebo treatment. The proportion of participants experiencing any adverse effect was mostly low, approximately two to three per cent of the total study population.

 

Steroids versus calcineurin inhibitors

In our analyses, there were no statistically significant differences between steroids and calcineurin inhibitors in terms of the assessed outcomes in three studies. In two studies, only the adverse events outcomes were of relevance to this review (Cicek 2009; Papp 2012). There were implications that adverse events may be more common in calcineurin inhibitor treatment when compared with steroids.

 
Total clearance (at four weeks or less of treatment)

There was no statistically significant difference between steroids and calcineurin inhibitors for this outcome in two studies with a combined total of 60 participants (RR 1.08, 95% CI 0.88 to 1.32) ( Analysis 2.1), and there were no conclusive statistical differences between a strong and a mild steroid when compared with calcineurin inhibitor. We rated the quality of the evidence as low ( Summary of findings for the main comparison).

 
Erythema (at four weeks or less of treatment)

One study with 37 participants examined the erythema scores at the end of treatment and found that there was no statistically significant difference between a mild steroid and calcineurin inhibitor (MD -0.05, 95% CI -0.22 to 0.12) ( Analysis 2.2).

 
Scaling (at four weeks or less of treatment)

One study with 38 participants examined the scaling scores at the end of treatment and found that there were no statistically significant differences between steroids and calcineurin inhibitors (MD 0.00, 95% CI -0.24 to 0.24) ( Analysis 2.3). Another study with 32 participants examined the mean change in dandruff scores, and the findings of this study were similar (MD -0.20, 95% CI -0.73 to 0.33) ( Analysis 2.4).

 
Pruritus (at four weeks or less of treatment)

One study with 37 participants examined pruritus scores and found that there were no statistically significant differences between a mild steroid and calcineurin inhibitor (Firooz 2006). We could not use the results of the trial in analyses for statistical reasons. (The standard deviations were 0.00 in the other treatment arm.)

 
Any adverse effects

Two studies with a combined total of 60 participants examined the incidence of adverse events when comparing calcineurin inhibitors with steroids for short-term treatment. Adverse events were found to be less common with steroid treatment (RR 0.22, 95% CI 0.05 to 0.89) ( Analysis 2.5). The most commonly reported adverse effects were erythema, burning, and prickling sensations.

Two studies with a combined total of 72 participants examined the incidence of adverse effects for long-term treatment. There was no statistically significant difference between steroid and calcineurin-inhibitor treatment (RR 0.62, 95% CI 0.26 to 1.47) ( Analysis 2.6). One study with 54 participants (Shin 2009) did not report adverse effects with sufficient detail.

 

Steroids versus azoles

No statistically significant differences were found between steroids and azoles in their efficacy in producing total clearance when evaluated by the investigator for short-term treatment, whereas when evaluated by the participant, azole treatment was found to be more effective than a mild steroid. For short-term treatment, the effect of azoles was milder than that of (at least strong) steroids on erythema, scaling, or pruritus. When long-term treatment was given, an azole compound was found to be more effective than a steroid compound in producing total clearance. There seemed to be no differences between steroids and azoles for adverse effects; however, in one study of long-term use, there were more adverse effects with a strong steroid than with an azole compound.

 
Total clearance (at four weeks or less of treatment)

A total of eight studies with a combined number of 464 participants assessed the comparative effectiveness of steroids and azoles in producing total clearance and found that there were no statistically significant differences between them (RR 1.11, 95% CI 0.94 to 1.32) when judged by the investigator ( Analysis 3.1). The finding was similar in studies investigating mild and strong steroids. We rated the quality of the evidence as moderate ( Summary of findings 2).

One study with 44 participants, which we did not include in the meta-analysis, reached inconclusive results (Reygagne 2007;  Table 1). There was also one study (62 participants) with conflicting results where azole treatment was more effective than steroid treatment in producing an excellent (this trial did not use total clearance as an outcome) response (Ortonne 1992).

Two studies assessed the comparative effectiveness of steroids and azoles in producing total clearance when judged by the participant. In one study with 101 participants, azole treatment was more effective in producing total clearance when compared with a mild steroid (RR 1.55, 95% CI 1.09 to 2.21) (Piepponen 1992), whereas in another study with 69 participants, there were no statistically significant differences between a strong steroid and an azole treatment (RR 0.99, 95% CI 0.80 to 1.23) (Van't Veen 1998) ( Analysis 3.2).

 
Erythema (at four weeks or less of treatment)

Three studies with a combined total of 160 participants addressed the effect of steroids and azoles on erythema evaluated by erythema scores at the end of treatment. One study (49 participants) comparing a strong steroid with azole found steroid to be more effective (MD -0.19, 95% CI -0.26 to -0.12) ( Analysis 3.3). In two studies comparing mild steroids with azoles (111 participants), the results were inconsistent (Kousidou 1992; Stratigos 1988). We could not use these trials in the analysis because of missing statistical data.

One study (101 participants, mild steroid) assessed the mean change in erythema scores. There was no statistically significant difference between the two treatments (MD 0.12, 95% CI -0.27 to 0.51) ( Analysis 3.4).

 
Scaling (at four weeks or less of treatment)

Two studies with a combined total of 118 participants addressed the effect of steroids when compared with azoles on scaling evaluated by scaling scores at the end of treatment. Strong steroids were associated with statistically significantly lower scaling scores (in favour of steroids) at the end of treatment (standardised mean difference (SMD) -2.72, 95% CI -3.24 to -2.21 for strong steroids, two studies) ( Analysis 3.5).

By contrast, there was a high degree of heterogeneity (I² statistic of 90%) between the results for the two trials comparing mild steroids with azoles (Kousidou 1992; Stratigos 1988, altogether 111 participants). The first mentioned trial found azole treatment to be more effective when compared with steroid (MD 0.92, 95% CI 0.26 to 1.59, 39 participants), whereas the results of the latter trial displayed no statistically significant difference between steroid and azole treatment (MD -0.38, 95% CI -0.85 to 0.08, 72 participants).

One study with 101 participants addressed the mean change in scaling scores and found that the treatments were equally effective (MD -0.05, 95% CI -0.40 to 0.30) ( Analysis 3.6).

 
Pruritus (at four weeks or less of treatment)

Five studies with a combined total of 260 participants assessed the effect of steroids and azoles on pruritus evaluated by pruritus scores at the end of treatment. One trial with mild steroids (Stratigos 1988, 72 participants) noted no statistically significant difference in pruritus at four weeks (72 participants). We could not use the results of this trial in the meta-analysis because of lack of statistical data. In the other trial with mild steroids, the treatments seemed comparable as well (MD 0.06, 95% CI -0.02 to 0.14, 39 participants) ( Analysis 3.7).

The results of three studies with strong steroids displayed a high degree of heterogeneity (I² statistic of 83%), and therefore we could not pool them together in a meta-analysis. However, in two of these trials, there were indications that strong steroids are more effective than azoles in reducing pruritus (MD -1.52, 95% CI -2.17 to -0.88, 49 participants in Hersle 1996) (MD -1.81, 95% CI -2.38 to -1.25, 69 participants in Van't Veen 1998), whereas in the third study, there were no statistically significant differences between a strong steroid and azole treatment (MD -0.28, 95% CI -0.99 to 0.43, 31 participants) (Pari 1998).

One study with 101 participants evaluated the mean change in pruritus scores and found that the treatments were equally effective (MD 0.03, 95% CI -0.36 to 0.42) ( Analysis 3.8).

 
Total clearance (at more than four weeks of treatment)

Only one study (Ortonne 1992), with 62 participants lasting four months, assessed clearance as a long-term outcome. However, this trial did not measure total clearance; instead, it evaluated excellent clearance. We did not predefine excellent clearance as an outcome of interest.

 
Any adverse effects

Three studies did not report adverse effects at all (Faergemann 1986; Fredriksson 1978; Pari 1998).

Altogether, six studies with a combined total of 381 participants reported the occurrence of any adverse effects at four weeks or less of treatment, and there was no statistically significant difference between steroid and azole treatment (RR 1.45, 95% CI 0.74 to 2.85) ( Analysis 3.9). Adverse effects most often reported were dryness of skin, burning, and dandruff. Dryness of skin was more often associated with steroid treatment than with azole treatment.

In the long-term studies (four weeks or more of treatment) comparing steroid and azole treatment, strong steroids seemed to produce adverse effects more often than azoles (RR 3.20, 95% CI 1.34 to 7.65, one study with 62 participants), whereas there were no statistically significant differences between mild steroid and azole treatment in one study with 43 participants (RR 0.48, 95% CI 0.22 to 1.04) ( Analysis 3.10).

 

Mild steroids versus strong steroids

We compared mild steroids (class I and II steroids) with strong steroids (class III or IV) in three studies. In general, there were no differences between mild and strong steroids with regard to the assessed outcomes including adverse effects.

 
Total clearance (at four weeks or less of treatment)

Two studies lasting four weeks or less, with 93 participants, assessed total clearance. We found that there were no statistically significant differences between mild or strong steroids whether total clearance was evaluated by the investigator (RR 0.96, 95% CI 0.65 to 1.40) ( Analysis 4.1;  Summary of findings 3) or by the participant (one study, 29 participants) (RR 1.03, 95% CI 0.65 to 1.61) ( Analysis 4.2). We rated the quality of the evidence as moderate.

 
Total clearance (at more than four weeks of treatment)

One study with 117 participants assessed total clearance at four weeks or more. In this study, we found a mild steroid to be more effective than a strong steroid (RR 0.79, 95% CI 0.63 to 0.98) (NNT 6, 95% CI 3 to 59) ( Analysis 4.3). We rated the quality of the evidence as low ( Summary of findings 4).

 
Erythema (at four weeks or less of treatment)

Two studies with a combined total of 55 participants assessed the effect of mild or strong steroids on erythema evaluated with erythema scores. We found that there was no statistically significant difference between mild and strong steroids (MD 0.10, 95% CI -0.34 to 0.54, one study, 35 participants) ( Analysis 4.4). Another trial (Ludvigsen 1983) with 20 participants supported this finding. We could not use the results of the latter trial in the analysis because of a lack of statistical data.

 
Scaling (at four weeks or less of treatment)

Two studies with a combined total of 63 participants assessed the effect of mild or strong steroids on scaling evaluated with scaling scores, and we found that there was no statistically significant difference (SMD -0.05, 95% CI -0.55 to 0.45) ( Analysis 4.5).

 
Pruritus (at four weeks or less of treatment)

Three studies with a combined total of 114 participants assessed the effect of mild or strong steroids on pruritus evaluated with pruritus scores, and we found that there was no statistically significant difference (SMD 0.13, 95% CI -0.24 to 0.50) ( Analysis 4.6).

 
Any adverse effects

When used in the short-term, there was no statistically significant difference between mild and strong steroids with regard to rate of adverse effects (RR 1.37, 95% CI 0.32 to 5.93) in three studies with a combined total of 118 participants ( Analysis 4.7), and in long-term use, the finding was similar (RR 5.90, 95% CI 0.73 to 47.49) in one study with 117 participants ( Analysis 4.8). The reported adverse effects were scalp dryness or appearance of papules or other kinds of rash.

 

Other comparisons for steroids

There were two additional studies that compared a mild steroid with another mild steroid (Cornell 1986; Cornell 1993), and one study compared a strong steroid with another strong steroid (Cornell 1989). We did not perform analyses on these studies as we were focusing on differences between different classes of drugs.

One study with 56 participants compared a strong steroid (betamethasone) with zinc pyrithione, and we found no statistically significant differences in their effect on scaling (MD -0.40, 95% CI -0.92 to 0.12) ( Analysis 5.1), but this study (Shin 2009) did not report adverse effects.

One study with 77 participants compared a mild steroid (desonide) with non-steroidal cream, Promiseb® (Elewski 2009a). There was no statistically significant difference in the effect on total clearance (RR 1.83, 95% CI 0.88 to 3.80) ( Analysis 6.1). In the same study, there were no statistically significant differences between the two drugs with regard to their ability to reduce erythema, scaling, or pruritus or to produce adverse effects.

One study with 60 participants compared steroid with calcipotriol (vitamin C compound) (Basak 2001). In this study, steroid proved to be more effective in accomplishing total clearance when compared with calcipotriol (RR 2.86, 95% CI 1.42 to 5.73) ( Analysis 7.1). Furthermore, the incidence of adverse effects was lower with steroid treatment than with calcipotriol treatment (RR 0.12, 95% CI 0.03 to 0.47) ( Analysis 7.2).

 

Calcineurin inhibitors versus comparators

We identified four studies comparing calcineurin inhibitors to steroids as described above. Of these, one study compared calcineurin inhibitor with azole and steroid, one compared calcineurin inhibitor with steroid and zinc pyrithione, one compared calcineurin inhibitor with placebo, and one compared calcineurin inhibitor with azole only.

 

Calcineurin inhibitors versus placebo

One study with 96 participants found calcineurin inhibitors to be more effective in reducing erythema and scaling when compared with placebo. There were no differences in total clearance or adverse effects between calcineurin inhibitors and placebo.

 
Total clearance (at four weeks or less of treatment)

We identified only one study (96 participants) assessing the effect of calcineurin inhibitors on total clearance when compared with placebo; there was no statistically significant difference in the effect on total clearance (RR 1.41, 95% CI 0.81 to 2.48) ( Analysis 8.1).

 
Erythema (at four weeks or less of treatment)

This study (results available for 86 participants) compared the effect of calcineurin inhibitors on erythema with placebo, and we found that calcineurin inhibitor was more effective in reducing erythema when evaluated by mean change in erythema scores (MD 0.40, 95% CI 0.06 to 0.74) ( Analysis 8.2).

 
Scaling (at four weeks or less of treatment)

This study (results available for 86 participants) compared the effect of calcineurin inhibitor on scaling with placebo. We found that calcineurin inhibitor was more effective in reducing scaling as evaluated by mean change in scaling scores (MD 0.30, 95% CI 0.00 to 0.60) ( Analysis 8.3).

 
Any adverse effects

In this study (results available for 86 participants), the proportion of participants experiencing adverse effects (at four weeks or less of treatment) was not statistically significantly different between the calcineurin inhibitor group and the placebo group (RR 1.43, 95% CI 0.87 to 2.37) ( Analysis 8.4). The nature of these adverse events was not reported.

 

Calcineurin inhibitors versus azoles

We identified two studies with a combined total of 90 participants assessing the effect of calcineurin inhibitors when compared with azoles. Of these, in one study, there were data concerning adverse effects relevant for this review. These two studies did not assess total clearance. With regard to efficacy outcomes, we identified no statistically significant differences between calcineurin inhibitors and azoles. Evidence concerning adverse effects was not conclusive.

 
Erythema (at four weeks or more of treatment)

In one study with 38 participants, we found no statistically significant differences between a calcineurin inhibitor and an azole in their effect on erythema evaluated with erythema scores at the end of treatment (MD 0.17, 95% CI -0.24 to 0.58) ( Analysis 9.1).

 
Scaling (at four weeks or more of treatment)

In the same study, we found the calcineurin inhibitor to be comparable to azole treatment in its effect on scaling evaluated with scaling scores at the end of treatment (MD -0.02, 95% CI -0.33 to 0.29) ( Analysis 9.2).

 
Any adverse effects

Two studies with a combined total of 90 participants addressed the incidence of adverse effects (at four weeks or more of treatment) ( Analysis 9.3). Their results were conflicting with a heterogeneity (I² statistic) of over 80%; therefore, we did not use their results in a meta-analysis. In a study with 42 participants, there were no statistically significant differences in adverse effect rate between calcineurin inhibitor treatment and azole treatment (Cicek 2009). In another trial with 58 participants, there were more adverse events in calcineurin inhibitor treatment when compared with azole treatment (Koc 2009). The trial reported burning, pruritus, and irritation as adverse effects.

 

Calcineurin inhibitors versus zinc pyrithione

One study compared calcineurin inhibitor (tacrolimus) with zinc pyrithione. It also included a comparison with a steroid. We found that when compared with zinc pyrithione, calcineurin inhibitor was more effective in reducing the dandruff scores (MD -0.60, 95% CI -1.01 to -0.19) ( Analysis 10.1). The study did not report adverse effects in sufficient detail (Shin 2009).

 

Lithium versus comparators

We identified two studies comparing lithium salts with placebo (Dreno 2002a; Langtry 1997) and one study comparing lithium salt with azole treatment (Dreno 2003). Lithium seemed to be more effective than placebo with regard to total clearance, but concerning erythema or scaling, there were no statistically significant differences between lithium and placebo. Lithium was also more effective when compared with azole with regard to total clearance. The differences between lithium and its comparators were ambiguous with regard to adverse effects, which were most often burning, erythema, dryness, and pruritus.

 

Lithium salts versus placebo

Lithium seems to be more effective when compared with placebo with regard to total clearance, with a comparable safety profile.

 
Total clearance (at four weeks or more of treatment)

Only one study with 129 participants assessed total clearance. We found that lithium was more effective than placebo (RR 8.59, 95% CI 2.08 to 35.52) (NNT 4, 95% CI 3 to 9) ( Analysis 11.1).

 
Erythema (at four weeks or less of treatment)

One study with 12 participants assessed the effect of lithium salts on erythema, comparing it to placebo (Langtry 1997). This study was a body-part study on HIV-positive male participants. At two weeks of treatment, It was found that there were no statistically significant differences in the percentage change in erythema scores between the lithium compound (30.7% of the baseline value) and placebo treatment (47.1% of the baseline value) (P = 0.055). However, at this point, 50% of the participants had already dropped out.

 
Scaling (at four weeks or less of treatment)

One study assessed the effect of lithium salts on scaling, comparing it to placebo. This study was a body-part randomisation study on 12 HIV-positive male participants (Langtry 1997). At two weeks of treatment, it was found that there were no statistically significant differences in the percentage change in erythema scores between the lithium compound (19.5% of the baseline value) and the placebo treatment (33.8% of the baseline value) (P = 0.76). However, at this point, 50% of the participants had already dropped out.

 
Any adverse effects

In one study lasting for eight weeks, there was no statistically significant difference between lithium and placebo in the occurrence of adverse effects (RR 0.72, 95% CI 0.31 to 1.66, 123 participants) ( Analysis 11.2). In this study, the adverse effects reported most often were burning, erythema, and pruritus. The report of the other study (Langtry 1997) comparing lithium to placebo was imprecise regarding adverse effects.

 

Lithium salts versus azoles

 
Total clearance (at four weeks or less of treatment)

One study with 288 participants compared the effect of lithium salt with azole on total clearance of SeD. In this study, we found that lithium salt was more effective (RR 1.79, 95% CI 1.10 to 2.90) ( Analysis 12.1) in terms of short-term results (four weeks). We rated the quality of the evidence as low ( Summary of findings 4).

 
Total clearance (at four weeks or more of treatment)

The results were similar at eight weeks (RR 1.79, 95% CI 1.32 to 2.43) ( Analysis 12.2).

 
Any adverse effects

This study reported adverse events in 26% of participants using topical lithium and in 25% of participants using topical azole treatment. Most commonly reported adverse events included erythema, burning, and dryness.

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
 

Summary of main results

We located 36 studies, of which 31 studies examined steroid as one intervention; seven examined calcineurin inhibitor as one intervention; and three examined lithium as one intervention.

Based on four studies, steroids increased the total clearance of all symptoms when compared with placebo, but with a similar safety profile both at four weeks and 12 weeks of follow-up. Steroids and calcineurin inhibitors had similar effects, but there were more often adverse effects with calcineurin inhibitor treatment than with steroid treatment. Compared with azoles, the effect varied between different outcomes. There were no differences between azole and steroid treatment regarding short-term total clearance. The effect of azoles on erythema, scaling, and pruritus was weaker than that of strong steroids. The rate of adverse effects was similar, at least in short-term use. In general, for short-term use, there were no differences between mild and strong steroids for outcomes including adverse effects.

Calcineurin inhibitors were more effective in reducing erythema and scaling when compared with placebo. Calcineurin inhibitors and azoles had similar effects and a similar rate of adverse effects.

Lithium was more effective than placebo with regard to total clearance, but there were no differences in erythema or scaling. The safety of these two was comparable. Lithium was also more effective than azoles with regard to total clearance with a similar safety profile.

The median rate of adverse effects was 7% in active treatment groups. Across treatments, the most commonly reported adverse effects were burning, itching, erythema, and dandruff. Some of these symptoms are similar to the symptoms of seborrhoeic dermatitis itself.

 

Overall completeness and applicability of evidence

We performed the literature searches without language restrictions up until September 2013. These searches provide assurance that we located the majority of studies on topical anti-inflammatory treatments for seborrhoeic dermatitis. Most studies included both men and women, and the age range was wide. Therefore, we consider the results to be applicable to both adult men and women. However, as pregnancy was a widely used exclusion criterion, it is unclear whether those who have seborrhoeic dermatitis when they are pregnant should use anti-inflammatory treatments. The studies rarely reported compliance rates. There were also multiple modes of delivering the interventions, which may account for some variation in the results. The trials covered several races including Caucasian and Asian participants, but not many people of African origin. This is important as seborrhoeic dermatitis may have a different pattern of symptoms in those with dark skin.

We only included trials investigating face or scalp involvement, and therefore the results of this review may not be applicable to people with seborrhoeic dermatitis affecting other parts of the body. It is also questionable whether the results can be generalised to people with dandruff but without the diagnosis of seborrhoeic dermatitis, as in most of the trials, the diagnosis of seborrhoeic dermatitis was an inclusion criteria. The available evidence does not allow us to determine whether there are differences in the effects of the assessed agents in different areas of the body or to make comparisons between the treatments in this regard.

The overwhelming majority of the trials were of short duration, whereas the disease itself is chronic in nature. Relapses often occur, sometimes triggered by environmental or individual stimuli. The available evidence does not cover the treatment effects (including side-effects) of repeated, long-term, or continuous use of anti-inflammatory agents. Seborrhoeic dermatitis cannot be cured, but the symptoms can be relieved.

This review did not include combination treatments in which an anti-inflammatory agent had been combined with an agent having another mechanism of action, such as an antimycotic or antiproliferative effect. There are also other topical treatments that may have anti-inflammatory effects (such as coal tar, selenium sulfide, and zinc). We did not include these treatments in the review however as their suggested modes of action have been classified as unclear or included additional mechanisms, such as antiproliferative, bacteriostatic, or fungistatic properties.

 

Quality of the evidence

For the main outcome (total clearance) and for the main comparisons, we assessed the quality of the evidence using the Grade Profiler software ( Summary of findings for the main comparison;  Summary of findings 2;  Summary of findings 4). For this outcome, the quality of the evidence was low to moderate.

For other outcomes, we also considered the quality of evidence as low to moderate on the basis of small sample sizes; short follow up; limitations in study design and reporting; and uncertainties in, or lack of blinding of, the participants, caregivers, or outcome assessors. In general, the level of evidence remains limited, and it is possible that further research may change the effect estimates substantially. The pharmaceutical industry sponsored most (21 trials, 58%) of the trials, or the study authors had considerable affiliations.

 

Potential biases in the review process

Two independent assessors assured the eligibility of the identified articles based on title or abstract. If either author regarded an article as possibly relevant, they retained the article for full-text assignment. Two independent authors also assessed the eligibility of the identified articles based on full text. We consider that the literature search was adequate and comprehensive.

We excluded reports that did not contain enough data (e.g. posters) if they gave results in a form not eligible for the purposes of the review (e.g. symptom scores were given as pooled, not separate, for each symptom), or if they only stated outcomes not relevant for this review (e.g. microbial growth indicators). We considered that this approach did not introduce bias.

If there were insufficient data in the included reports, we excluded the studies from the meta-analyses. Nevertheless, we described the results qualitatively when the reports used prespecified outcomes.

 

Agreements and disagreements with other studies or reviews

We identified a recently published systematic review on pimecrolimus cream for the treatment of seborrhoeic dermatitis (Ang-Tiu 2012). We have considered all the trials included in that review (Cicek 2009; Firooz 2006; Koc 2009; Warshaw 2007) in our Cochrane review as well. The conclusions of the authors concerning clinical efficacy are consistent with our conclusions.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes

 

Implications for practice

Topical steroids and lithium salts are more effective than placebo in achieving total clearance in seborrhoeic dermatitis of the face or scalp. Calcineurin inhibitors show benefit over placebo in reducing erythema and scaling. Azoles may be comparable to steroids in achieving total clearance, but there are implications that strong steroids are more efficient with symptoms like erythema, scaling, and pruritus. Furthermore, adverse effects occur at a similar rate at four weeks' follow-up. Calcineurin inhibitors seem to be comparable with azoles and steroids concerning efficacy. Lithium is more effective than azole with regard to total clearance. Mild and strong steroids seemed to be comparable with regard to efficacy and adverse effects in up to six weeks' follow-up. However, there are no data regarding the efficacy or safety of repeated, long-term (such as more than one year), or continuous use of any of the assessed medicines.

The median rate of achieving total clearance was 53% with anti-inflammatory treatments across studies. This is an indication of the need for further research to identify optimal treatment agents, possibly treatment combinations, regimens, and length.

 
Implications for research

To prevent reporting bias, authors should first publish a protocol of their study and register this in a trials registration database. To further increase the quality of evidence of topical anti-inflammatory treatments for seborrhoeic dermatitis, future trials should deal with the following issues.

  • Quality of methods: Trials should properly conduct and report random sequence allocation, as well as allocation concealment and the method of blinding.
  • Quality of reporting: Trials should report results in numbers, preferably in tables, instead of graphs, as well as reporting standard deviations and exact P values.
  • Outcomes: There is an urgent need for one or more validated outcome measures for seborrhoeic dermatitis that should at least cover erythema, scaling, pruritis, and the area of the body and the amount of skin affected. Trials should also examine patient-centered outcomes, such as quality-adjusted life measures, as well as compliance. Trials should measure outcomes at long-term follow up, such as one year after starting treatment, in order to assess the relapse rate or the efficacy in long-term use. For adverse effects, we need measurements at several years of follow up.
  • Economic evaluations: Trials should put the therapeutic value of a treatment into context with its economic value in order to be able to use treatments rationally.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes

We would like to thank the Cochrane Occupational Safety and Health Review Group for their training and support.

The Cochrane Skin Group editorial base wishes to thank Hywel Williams who was the Cochrane Dermatology Editor for this review; Matthew Grainge and Ching-Chi Chi who were the Statistical and Methods Editors, respectively; the clinical referees, Charlene U Ang-Tiu and Ana Luisa Sampaio; and the consumer referee, Jack Tweed.

We are grateful to Mr Jong-Myon Bae, MD, PhD, and Miss Quan Yang, PhD, for their help in translating articles.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
Download statistical data

 
Comparison 1. Steroid vs placebo

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Total clearance (at 4 weeks or less)3313Risk Ratio (M-H, Random, 95% CI)3.76 [1.22, 11.56]

    1.1 Mild steroids
147Risk Ratio (M-H, Random, 95% CI)1.57 [0.29, 8.53]

    1.2 Strong steroids
2266Risk Ratio (M-H, Random, 95% CI)5.92 [0.99, 35.52]

 2 Total clearance (over 4 weeks)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Strong steroids
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Mean change in erythema score (at 4 weeks or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 Strong steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Erythema score (at 4 weeks or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 Strong steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Mean change in scaling score (at 4 weeks or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    5.1 Strong steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 6 Scaling scores (at 4 weeks or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 Strong steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Mean change in pruritus score (at 4 weeks or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    7.1 Strong steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 8 Pruritus scores (at 4 weeks or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    8.1 Strong steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 9 Any adverse effect (at 4 weeks or less)3508Risk Ratio (M-H, Fixed, 95% CI)0.89 [0.29, 2.72]

    9.1 Mild steroids
147Risk Ratio (M-H, Fixed, 95% CI)0.35 [0.01, 8.11]

    9.2 Strong steroids
2461Risk Ratio (M-H, Fixed, 95% CI)1.05 [0.31, 3.58]

 
Comparison 2. Steroid vs calcineurin inhibitor

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Total clearance (at 4 weeks or less)260Risk Ratio (M-H, Fixed, 95% CI)1.08 [0.88, 1.32]

    1.1 Mild steroids
140Risk Ratio (M-H, Fixed, 95% CI)1.13 [0.83, 1.55]

    1.2 Strong steroids
120Risk Ratio (M-H, Fixed, 95% CI)1.0 [0.83, 1.20]

 2 Erythema score (at 4 weeks or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 Mild steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Scaling score (at 4 weeks or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 Mild steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Mean change in dandruff score (at 4 weeks or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 Strong steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Any adverse effects at 4 weeks or less260Risk Ratio (M-H, Fixed, 95% CI)0.22 [0.05, 0.89]

    5.1 Mild steroids
140Risk Ratio (M-H, Fixed, 95% CI)0.14 [0.02, 1.06]

    5.2 Strong steroids
120Risk Ratio (M-H, Fixed, 95% CI)0.41 [0.05, 3.28]

 6 Any adverse effects (at 4 weeks or more)272Risk Ratio (M-H, Fixed, 95% CI)0.62 [0.26, 1.47]

    6.1 Mild steroids
272Risk Ratio (M-H, Fixed, 95% CI)0.62 [0.26, 1.47]

 
Comparison 3. Steroid vs azole

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Total clearance (at 4 weeks or less)8464Risk Ratio (M-H, Fixed, 95% CI)1.11 [0.94, 1.32]

    1.1 Mild steroids
5310Risk Ratio (M-H, Fixed, 95% CI)1.06 [0.87, 1.28]

    1.2 Strong steroids
3154Risk Ratio (M-H, Fixed, 95% CI)1.29 [0.88, 1.90]

 2 Total clearance (at 4 weeks or less, evaluated by participant)2Risk Ratio (M-H, Random, 95% CI)Totals not selected

    2.1 Mild steroids
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

    2.2 Strong steroids
1Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 3 Erythema score (at 4 weeks or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    3.1 Strong steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Mean change in erythema score at 4 weeks or less1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 Mild steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 5 Scaling score (at 4 weeks or less)2Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

    5.1 Strong steroids
2118Std. Mean Difference (IV, Fixed, 95% CI)-2.72 [-3.24, -2.21]

 6 Mean change in scaling score at 4 weeks or less1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    6.1 Mild steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 7 Pruritus score (at 4 weeks or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    7.1 Mild steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 8 Mean change in pruritus score at 4 weeks or less1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    8.1 Mild steroids
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 9 Any adverse effects at 4 weeks or less6381Risk Ratio (M-H, Fixed, 95% CI)1.45 [0.74, 2.85]

    9.1 Mild steroids
4263Risk Ratio (M-H, Fixed, 95% CI)1.00 [0.44, 2.26]

    9.2 Strong steroids
2118Risk Ratio (M-H, Fixed, 95% CI)3.25 [0.86, 12.36]

 10 Any adverse effects at 4 weeks or more2Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    10.1 Mild steroids
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    10.2 Strong steroids
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 4. Mild steroid vs strong steroid

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Total clearance (at 4 weeks or less)293Risk Ratio (M-H, Fixed, 95% CI)0.96 [0.65, 1.40]

 2 Total clearance (at 4 weeks or less, evaluated by participant)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 3 Total clearance at 4 weeks or more1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 4 Erythema score (at 4 weeks or less)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 5 Scaling score (at 4 weeks or less)263Std. Mean Difference (IV, Fixed, 95% CI)-0.05 [-0.55, 0.45]

 6 Pruritus score (at 4 weeks or less)3114Std. Mean Difference (IV, Fixed, 95% CI)0.13 [-0.24, 0.50]

 7 Any adverse effects (at 4 weeks or less)3118Risk Ratio (M-H, Fixed, 95% CI)1.37 [0.32, 5.93]

 8 Any adverse effects (at 4 weeks or more)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 5. Steroid vs zinc pyrithione

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Scaling score (< 4 weeks)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 
Comparison 6. Desonide (mild steroid) vs Promiseb®

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Total clearance (at 4 weeks or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 7. Steroid vs calcipotriol

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Total clearance (at 4 weeks or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Any adverse effects (at 4 weeks or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 8. Calcineurin inhibitor vs placebo

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Total clearance (at 4 weeks or less)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Mean change in erythema score at 4 weeks or less1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Mean change in scaling score at 4 weeks or less1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 4 Outcome: any adverse effects1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 9. Calcineurin inhibitor vs azole

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Erythema score (over 4 weeks)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 2 Scaling score (over 4 weeks)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Any adverse effects (over 4 weeks)2Risk Ratio (M-H, Random, 95% CI)Totals not selected

 
Comparison 10. Calcineurin inhibitor vs zinc pyrithione

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Dandruff score (< 4 weeks)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 
Comparison 11. Lithium vs placebo

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Total clearance (over 4 weeks)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Any adverse effects at 4 weeks or more1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 
Comparison 12. Lithium vs azole

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Total clearance (< 4 weeks)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 2 Total clearance (at 4 weeks or more)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
 

Appendix 1. CENTRAL (Cochrane Library) search strategy

#1 MeSH descriptor: [Malassezia] this term only
#2 ("scalp dermatoses" or "scalp dermatosis" or "scalp dermatitis" or "scalp eczema"):ti,ab,kw
#3 ("seborrheic dermatitis" or "seborrhoeic dermatitis" or malassezia or "cradle cap" or dandruff or "seborrheic eczema" or "seborrhoeic eczema"):ti,ab,kw
#4 MeSH descriptor: [Dermatitis, Seborrheic] this term only
#5 MeSH descriptor: [Scalp Dermatoses] this term only
#6 #1 or #2 or #3 or #4 or #5

 

Appendix 2. MEDLINE (OVID) search strategy

1. exp Dermatitis, Seborrheic/
2. seborrh$ dermatitis.mp.
3. scalp dermatos$.mp.
4. exp Scalp Dermatoses/
5. scalp dermatitis.mp.
6. scalp eczema.mp.
7. dandruff.mp.
8. Malassezia.mp. or exp Malassezia/
9. cradle cap.mp.
10. seborrh$ eczema.mp.
11. or/1-10
12. randomized controlled trial.pt.
13. controlled clinical trial.pt.
14. randomized.ab.
15. placebo.ab.
16. clinical trials as topic.sh.
17. randomly.ab.
18. trial.ti.
19. 12 or 13 or 14 or 15 or 16 or 17 or 18
20. exp animals/ not humans.sh.
21. 19 not 20
22. 11 and 21

 

Appendix 3. Embase (OVID) search strategy

1. random$.mp.
2. factorial$.mp.
3. (crossover$ or cross-over$).mp.
4. placebo$.mp. or PLACEBO/
5. (doubl$ adj blind$).mp.
6. (singl$ adj blind$).mp.
7. (assign$ or allocat$).mp.
8. volunteer$.mp. or VOLUNTEER/
9. Crossover Procedure/
10. Double Blind Procedure/
11. Randomized Controlled Trial/
12. Single Blind Procedure/
13. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12
14. Seborrh$ dermatitis.ti,ab.
15. scalp dermatitis.ti,ab.
16. scalp eczema.ti,ab.
17. cradle cap.ti,ab.
18. exp *dandruff/
19. exp *Malassezia/
20. dandruff.ti,ab.
21. malassezia.ti,ab.
22. exp *seborrheic dermatitis/
23. scalp dermatos$.ti,ab.
24. seborrh$ eczema.ti,ab.
25. or/14-24
26. 13 and 25

 

Appendix 4. LILACS search strategy

((Pt RANDOMIZED CONTROLLED TRIAL OR Pt CONTROLLED CLINICAL TRIAL OR Mh RANDOMIZED CONTROLLED TRIALS OR Mh RANDOM ALLOCATION OR Mh DOUBLE-BLIND METHOD OR Mh SINGLE-BLIND METHOD OR Pt MULTICENTER STUDY) OR ((tw ensaio or tw ensayo or tw trial) and (tw azar or tw acaso or tw placebo or tw control$ or tw aleat$ or tw random$ or (tw duplo and tw cego) or (tw doble and tw ciego) or (tw double and tw blind)) and tw clinic$)) AND NOT ((CT ANIMALS OR MH ANIMALS OR CT RABBITS OR CT MICE OR MH RATS OR MH PRIMATES OR MH DOGS OR MH RABBITS OR MH SWINE) AND NOT (CT HUMAN AND CT ANIMALS)) [Words] and “seborrh$ dermatitis” or seborreico or dandruff or caspa or “cradle cap” or “costra lactea” or malassezia or “scalp dermatos$” or “eczema seborreico” or “dermatitis seborreica” [Words]

 

What's new

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes

Last assessed as up-to-date: 18 September 2013.


DateEventDescription

9 July 2015AmendedA search of MEDLINE and Embase in June 2015 found studies that were, in the main, looking at single interventions, which are unlikely to alter the overall conclusion. There are a few small studies on sertaconazole, but not quite enough to merit an update, so an update has not been considered necessary at this time. Our Trials Search Co-ordinator will run a new search in summer 2016 to re-assess whether an update is needed.



 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes

HK was the contact person with the editorial base.
HK co-ordinated the contributions from the co-authors.
HK, TOk, PP, TOr, and JJ screened papers against eligibility criteria.
HK and TOk obtained data on ongoing and unpublished studies.
HK and TOk appraised the quality of papers.
HK, TOk, and JJ extracted data for the review and sought additional information about papers.
TOk and HK entered data into RevMan.
HK and VK analysed and interpreted data.
VK, HK, and TOk worked on the methods sections.
HK, EO, and TOk drafted the clinical sections of the background and responded to the clinical comments of the referees.
KA commented on the drafts (protocol and review).
JV was the consumer co-author and checked the review for readability and clarity, as well as ensuring outcomes are relevant to consumers.
JV is the guarantor of the review.

Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health, UK, or the Finnish Medicines Agency Fimea.

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes

PP has received a research grant from AstraZeneca and consultancy fees from ESiOR Ltd (a health economy consultancy that provides research and consulting services to the pharmaceutical industry). These projects have not been related to treatment for seborrhoeic dermatitis.

None of the other authors involved in this review have declared any interests.

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes
 

Internal sources

  • Finnish Medicines Agency (FIMEA), Finland.
  • The Finnish Institute of Occupational Health, Finland.
  • The Cochrane Occupational Safety and Health Review Group, Finland.
  • The Nigerian Branch of the South African Cochrane Centre, Nigeria.

 

External sources

  • The National Institute for Health Research (NIHR), UK.
    The NIHR, UK, is the largest single funder of the Cochrane Skin Group.

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes

In the protocol under Types of participants, we stated that we would include studies of adults or adolescents (> 16 years) with SeD. When assessing the eligibility of the trials, we used the percentage of 75 or more as a measure to judge whether the trial fulfilled this inclusion criterion. We made the decision that at least 75% of the study participants had to be over 10 years of age to fulfil the age criterion.

We did not explore heterogeneity other than regarding the strength of steroid treatment where feasible. This is reasoned by the small number of studies in each comparison. In the protocol, we planned to possibly explore age, gender, and dose (frequency) distributions as a cause for heterogeneity.

Two additional authors (JJ and TOr) were added to the people undertaking the data collection and analysis. An additional resource was added to electronic searches (GREAT).

 

Notes

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Notes

A search of MEDLINE and Embase in June 2015 found studies that were, in the main, looking at single interventions, which are unlikely to alter the overall conclusion. There are a few small studies on sertaconazole, but not quite enough to merit an update, so an update has not been considered necessary at this time. Our Trials Search Co-ordinator will run a new search in summer 2016 to re-assess whether an update is needed.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
Attila 1992 {published data only}
  • Attila P, Förström L, Hannuksela M, Karvonen J, Lehtonen L, Salo OP. Clotrimazole-hydrocortisone, hydrocortisone and propylene glycol liniment in the treatment of seborrhoeic dermatitis of the scalp. Journal of Dermatological Treatment 1992;3(4):185-8. [EMBASE: 1993020255]
Basak 2001 {published data only}
Cicek 2009 {published data only}
  • Cicek D, Kandi B, Bakar S, Turgut D. Pimecrolimus 1% cream, methylprednisolone aceponate 0.1% cream and metronidazole 0.75% gel in the treatment of seborrhoeic dermatitis: a randomized clinical study. Journal of Dermatological Treatment 2009;20(6):344-9. [MEDLINE: 19954391]
Cornell 1986 {published data only}
  • Cornell RC. Atrophogenic potential of alclometasone dipropionate ointment 0.05% vs hydrocortisone ointment 1.0%. Current Therapeutic Research Clinical & Experimental 1986;39(2):260-8. [EMBASE: 1987091141]
Cornell 1989 {published data only}
  • Cornell RC, Ellis CN. Comparison of the efficacy and safety of amcinonide lotion 0.1% with those of betamethasone valerate lotion 0.1% in patients with seborrheic dermatitis. Current Therapeutic Research Clinical & Experimental 1989;46(3):577-86. [EMBASE: 1989232568]
Cornell 1993 {published data only}
  • Cornell RC, Baker MD. Dermal safety comparison of 0.05% desonide cream and 1.0% hydrocortisone cream. Current Therapeutic Research Clinical & Experimental 1993;53(4):356-9. [EMBASE: 1993234707]
Dreno 2002a {published data only}
  • Dreno B, Moyse D. Lithium gluconate in the treatment of seborrhoeic dermatitis: a multicenter, randomised, double-blind study versus placebo. European Journal of Dermatology 2002;12(6):549-52. [EMBASE: 2002448306]
  • Dreno B, Revuz J, Chosidow O, Bayrou O, Beylot C, Bonnetblanc JM, et al. Lithium gluconate 8% ointment in the treatment of moderate to severe seborrhoeic dermatitis. Journal of the European Academy of Dermatology & Venereology 2002;16(Suppl 1):153.
Dreno 2003 {published data only}
  • Dreno B, Chosidow O, Revuz J. Lithium vs ketoconazole in seborrheic dermatitis: a multicenter, randomized, controlled study. Annales of Dermatology & Venereology 2002;129(1):S696.
  • Dreno B, Chosidow O, Revuz J, Moyse D, Study Investigator Group. Lithium gluconate 8% vs. ketoconazole 2% in the treatment of seborrhoeic dermatitis: a multicentre, randomized study. British Journal of Dermatology 2003;148(6):1230-6. [MEDLINE: 12828753]
Elewski 2009a {published data only}
  • Elewski B. An investigator-blind, randomized, 4-week, parallel-group, multicenter pilot study to compare the safety and efficacy of a nonsteroidal cream (Promiseb Topical Cream) and desonide cream 0.05% in the twice-daily treatment of mild to moderate seborrheic dermatitis of the face. Clinics in Dermatology 2009;27(6 Suppl):S48-53. [MEDLINE: 19878781]
Faergemann 1986 {published data only}
Firooz 2006 {published data only}
  • Firooz A, Solhpour A, Gorouhi F, Daneshpazhooh M, Balighi K, Farsinejad K, et al. Pimecrolimus cream, 1%, vs hydrocortisone acetate cream, 1%, in the treatment of facial seborrheic dermatitis: a randomized, investigator-blind, clinical trial. Archives of Dermatology 2006;142(8):1066-7. [MEDLINE: 16924062]
Fredriksson 1978 {published data only}
  • Fredriksson T. A comparison between hydrocortisone 17-butyrate and betamethasone 17α-valerate in seborrhoeic dermatitis of the scalp. IRCS Medical Science: Clinical Medicine; Clinical Pharmacology and Therapeutics; Connective Tissue, Skin and Bone 1978;6(2):70. [EMBASE: 0979014893]
General Practitioner 1982 {published data only}
  • General Practitioner Research Group. Topical corticosteroids in seborrhoeic dermatitis. A report from the general practitioner research group. Practitioner 1982;226(1368):1178-9. [EMBASE: 1982217563]
Gip 1979 {published data only}
  • Gip L. A study to compare the efficacy of hydrocortisone 17-butyrate (Locoid) 0.1% scalp lotion and betamethasone 17-valerage (Betnovate) 0.1% lotion in the treatment of seborrhoeic dermatitis of the scalp. Current Therapeutic Research Clinical & Experimental 1979;26(5):607-10. [EMBASE: 1980112442]
Harris 1972 {published data only}
  • Harris JJ. A national double-blind clinical trial of a new corticosteroid lotion: a 12-investigator cooperative analysis. Current therapeutic research, clinical & experimental 1972;14(9):638-46. [EMBASE: 4263888]
Hersle 1996 {published data only}
  • Hersle K, Mobacken H, Nordin P. Mometasone furoate solution 0.1% compared with ketoconazole shampoo 2% for seborrheic dermatitis of the scalp. Current Therapeutic Research Clinical & Experimental 1996;57(7):516-22. [EMBASE: 1996233065]
Katsambas 1989 {published data only}
  • Katsambas A, Antoniou C, Frangouli E, Avgerinou G, Michailidis D, Stratigos J. A double-blind trial of treatment of seborrheic dermatitis with 2% ketoconazole cream compared with 1% hydrocortisone cream. British Journal of Dermatology 1989;121(3):353-7. [EMBASE: 1989222189]
Koc 2009 {published data only}
  • Koc E, Arca E, Kose O, Akar A. An open, randomized, prospective, comparative study of topical pimecrolimus 1% cream and topical ketoconazole 2% cream in the treatment of seborrheic dermatitis. Journal of Dermatological Treatment 2009;20(1):4-9. [EMBASE: 2009111157]
Kousidou 1992 {published data only}
  • Kousidou T, Panagiotidou D, Boutli F, Mourellou O, Ioannidis D, Fotidou D, et al. A double-blind comparison of 2% ketoconazole cream and 1% hydrocortisone cream in the treatment of seborrheic dermatitis. Current Therapeutic Research, Clinical & Experimental 1992;51(5):723-9. [EMBASE: 1992159176]
Langtry 1997 {published data only}
Ludvigsen 1983 {published data only}
  • Ludvigsen K. Treatment of seborrhoeic dermatitis of the scalp. Report of a double-blind comparative trial of hydrocortisone 17-butyrate 0.1% lotion (Locoid) and betamethasone 17,21-Dipropionate 0.05% Lotion (Diproderm). Clinical Trials Journal 1983;20(6):313-8. [EMBASE: 1984018112]
Lynfield 1988 {published data only}
  • Lynfield Y, Cornell RC, Horwitz SN, Huntley AC, Millikan LE. Amcinonide lotion 0.1% in the treatment of patients with seborrheic dermatitis of the scalp and/or other hairy areas. Current Therapeutic Research Clinical & Experimental 1988;44(2):304-14. [EMBASE: 1989002094]
Medansky 1992 {published data only}
  • Medansky RS, Lepaw MI, Shavin JS, Zimmerman EH, Jones ML, Peets EA, et al. Mometasone furoate cream 0.1% vs. hydrocortisone cream 1% in the treatment of seborrhoeic dermatitis. Journal of Dermatological Treatment 1992;3(3):125-8. [EMBASE: 1992296411]
Ortonne 1992 {published data only}
  • Ortonne J-P, Lacour J-P, Vitetta A, Le Fichoux Y. Comparative Study of Ketoconazole 2% Foaming Gel and Betamethasone Dipropionate 0,05% Lotion in the Treatment of Seborrhoeic Dermatitis in Adults. Dermatology 1992;184(4):275-80. [EMBASE: 1992177939]
Ortonne 2011 {published data only}
  • Ortonne JP, Nikkels AF, Reich K, Ponce Olivera RM, Lee JH, Kerrouche N, et al. Efficacious and safe management of moderate to severe scalp seborrhoeic dermatitis using clobetasol propionate shampoo 0.05% combined with ketoconazole shampoo 2%: a randomized, controlled study. British Journal of Dermatology 2011;165(1):171-6. [EMBASE: 2011355146]
Papp 2012 {published data only}
  • Papp KA, Papp A, Dahmer B, Clark CS. Single-blind, randomized controlled trial evaluating the treatment of facial seborrheic dermatitis with hydrocortisone 1% ointment compared with tacrolimus 0.1% ointment in adults. Journal of the American Academy of Dermatology 2012;67(1):e11-5. [EMBASE: 2012342025]
Pari 1998 {published data only}
  • Pari T, Pulimood S, Jacob M, George S, Jeyaseelan L, Thomas K. Randomized double blind controlled trial 2% ketoconazole cream versus 0,05% clobetasol 17-butyrate cream in seborrhoeic dermatitis. Journal of the European Academy of Dermatology & Venereology 1998; Vol. 10, issue 1:89-90. [EMBASE: 1998052808]
Piepponen 1992 {published data only}
  • Piepponen T, Suhonen R, Rantanen T, Blomqvist K, Pajarre R, Lehtonen L. Treatment of dandruff with a ketoconazole 2% shampoo. Journal of Dermatological Treatment 1992;3(3):119-23. [EMBASE: 1992296410]
Ramirez 1993 {published data only}
  • Ramirez RG, Dorton D. Double-blind placebo-controlled multicentre study of fluocinolone acetonide shampoo (FS Shampoo) in scalp seborrhoeic dermatitis. Journal of Dermatological Treatment 1993;4(3):135-7. [EMBASE: 1993311639]
Reygagne 2007 {published data only}
  • Reygagne P, Poncet M, Sidou F, Soto P. Clobetasol propionate shampoo 0.05% in the treatment of seborrheic dermatitis of the scalp: results of a pilot study. Cutis 2007;79(5):397-403. [EMBASE: 17569404]
Rigopoulos 2004 {published data only}
Rudner 1970 {published data only}
  • Rudner EJ, Samovitz M. Seborrheic Dermatitis of the Face - Treated with Fluocinolone Acetonide Solution: A Double Blind Study. Cutis 1970;6:320-2.
Shin 2009 {published data only}
Stratigos 1988 {published data only}
  • Stratigos J, Antoniou C, Katsambas A, Böhler K, Fritsch P, Schmölz A, et al. Ketoconazole 2% cream versus hydrocortisone 1% cream in the treatment of seborrheic dermatitis. A double-blind comparative study. Journal of the American Academy of Dermatology 1988;19(5 Pt 1):850-3. [MEDLINE: 2973476]
Van't Veen 1998 {published data only}
  • Van't Veen AJ, Prevoo RLMA, Velders AJ, Jagtman BA, van Niel JCG, Stolz E. Betamethasone-17-valerate compared with ketoconazole for topical treatment of seborrhoeic dermatitis of the scalp in adults. Results of a Dutch multicenter study. Journal of Dermatological Treatment 1998;9(4):239-45. [EMBASE: 1999025626]
Warshaw 2007 {published data only}
  • Warshaw EM, Wohlhuter RJ, Liu A, Zeller SA, Wenner RA, Bowers S, et al. Results of a randomized, double-blind, vehicle-controlled efficacy trial of pimecrolimus cream 1% for the treatment of moderate to severe facial seborrheic dermatitis. Journal of the American Academy of Dermatology 2007;57(2):257-64. [MEDLINE: 17188780]

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
Aertgeerts 1985 {published data only}
  • Aertgeerts P, Albring M, Klaschka F, Nasemann T, Patzelt-Wenczler R, Rauhut K, et al. Comparative testing of Kamillosan cream and steroidal (0.25% hydrocortisone, 0.75% fluocortin butyl ester) and non-steroidal (5% bufexamac) dermatologic agents in maintenance therapy of eczematous diseases [Vergleichende Prufung von Kamillosan Creme gegenuber steroidalen (0,25% Hydrocortison, 0,75% Fluocortinbutylester) und nichtsteroidalen (5% Bufexamac) Externa in der Erhaltungstherapie von Ekzemerkrankungen]. Zeitschrift für Hautkrankheiten 1985;60(3):270-7. [EMBASE: 3158124]
Albrecht 1986 {published data only}
  • Albrecht G. Berlin Multicenter Study on Prednicarbate Preparations in Dermatologic Practices [Das Berliner Modell. Multicenterstudie mit Prednicarbat in verschiedenen Vehikeln]. Zeitschrift für Hautkrankheiten 1986;61(Suppl 1):88-96. [MEDLINE: 2939636]
Alebiosu 2003 {published data only}
  • Alebiosu CO, Ogunledun A, Ogunleye DS. A report of clinical trial conducted on Toto ointment and soap products. Journal of the National Medical Association 2003;95(1):95-105. [MEDLINE: 12656456]
Alexander 1967 {published data only}
Amos 1994 {published data only}
  • Amos HE, MacLennan AI, Boorman GC. Clinical efficacy of Polytar AF (Fongitar) and Nizoral scalp treatments in patients with dandruff/seborrhoeic dermatitis. Journal of Dermatological Treatment 1994;5(3):127-30. [EMBASE: 1994316061]
Anonymous 1994a {published data only}
  • Anonymous. Management of seborrhoic dermatitis [Therapie der seborrhoischen Dermatitis]. Der Hautarzt 1994;45(4 Suppl):1-4. [EMBASE: 9218049]
Anonymous 1994b {published data only}
  • Anonymous. Seborrheic dermatitis: Lithium deprives the growth basis of yeast fungus [Seborrhoische Dermatitis: Lithium entzieht Hefepilz die Wachstumsgrundlage]. Therapiewoche 1994;44(18):1032-3. [EMBASE: 1994176542]
Arenas 1999 {published data only}
  • Arenas R, Monroy E, Farrera RF, Abiega CD. Double blind and aleatory study to evaluate efficacy of icthiol/octopirox/salicilic acid in seborrehic dermatitis [Estudio doble ciego, al azar, para evaluar la eficacia de ictiol/octopirox/acido salicilico en dermatitis seborreica de la piel cabelluda]. Dermatologia Revista Mexicana 1999;43(4):157-63. [EMBASE: 1999365285]
Attarzadeh 2013 {published data only}
  • Attarzadeh Y, Asilian A, Shahmoradi Z, Adibi N. Comparing the efficacy of emu oil with clotrimazole and hydrocortisone in the treatment of seborrheic dermatitis: a clinical trial. Journal of Research in Medical Sciences 2013;18(6):477-81. [MEDLINE: 24250695]
Banerjee 1975 {published data only}
  • Banerjee BN, Mandal SB, Dutta AK. Evaluation of furacin-s (nitrofurazone and hydrocortisone acetate) in the treatment of different dermatoses. Indian Journal of Dermatology, Venerology & Leprology 1975;41(6):209-14. [EMBASE: 0977052085]
Barbanoj 2005 {published data only}
  • Barbanoj MJ, Antonijoan R, Garcia-Gea C, Puntes M, Gich I, Jane F. Eberconazole cream: topical and general tolerability, sensitisation potential, and systemic availability. Methods & Findings in Experimental & Clinical Pharmacology 2005;27(4):227-34. [EMBASE: 2005220616]
Basak 1999 {published data only}
  • Başak PY, Ergin Ş. Comparative effects of calcipotriol and betamethasone 17-valerate in seborrhoeic dermatitis of the scalp [Abstract P-547]. The 8th Congress of the European Academy of Dermatology and Venereology. Amsterdam, The Netherlands 29thSept-3rd October 1999. Journal of European Adacemy of Dermatology and Venereology 1999;12(Suppl 2):S295.
Bertamino 1975 {published data only}
  • Bertamino R. A new topical corticosteroid. Its evaluation in a double-blind trial [Un nuovo Corticosteroide per uso topico. Sua valutazione in condizioni di doppia cecità]. Riforma Medica 1975;89(15):706-13. [EMBASE: 0976142422]
Binder 1972 {published data only}
  • Binder R, McCleary J. Comparison of fluocinonide in a double-blind study with betamethasone valerate. Current Therapeutic Research 1972;14(1):35-8. [EMBASE: 4257862]
Boyle 1986 {published data only}
Camarasa 1975 {published data only}
  • Camarasa G. Clinical testing of a new local corticoid: desoxymethasone [Klinische Erprobung eines neuen lokalen Kortikoids: Desoximetason]. Zeitschrift für Hautkrankheiten 1975;50(Suppl 2):21-4. [EMBASE: 132780]
Carboni 1982 {published data only}
  • Carboni G, Longhi-Gelati M, Pierfelice V. Clinical observations on two new liquid forms of clobetasol propionate in seborrhoeic eczema [Osservazioni cliniche su due nuove forme liquide di clobetasolo propionato sull'eczema seborroico]. Giornale Italiano di Dermatologia e Venereologia 1982;117(1):V-X. [EMBASE: 1982225929]
Christodoulou 1983 {published data only}
  • Christodoulou GN, Georgala S, Vareltzides A, Catsarou A. Lithium in seborrheic dermatitis. Psychiatric Journal of the University of Ottawa 1983;8(1):27-9. [EMBASE: 1983187066]
Cuelenaere 1992 {published data only}
Curley 1990 {published data only}
  • Curley RK, Vickers CF, Norris T, Glover DR. A comparative study of betamethasone dipropionate with salicylic acid and betamethasone valerate for the treatment of steroid-responsive dermatoses of the scalp. Journal of Dermatological Treatment 1990;1(4):203-6. [EMBASE: 1990343409]
Davies 1999 {published data only}
  • Davies DB, Boorman GC, Shuttleworth D. Comparative efficacy of shampoos containing coal tar (4.0% w/W;TarmedTM), coal tar (4.0% w/w) plus ciclopirox olamine (1.0% w/w; TarmedTM AF) and ketoconazole (2.0% w/w; Nizoral®) for the treatment of dandruff/seborrhoeic dermatitis. Journal of Dermatological Treatment 1999;10(3):177-83. [EMBASE: 1999324981]
de la Brassine 1984 {published data only}
  • de la Brassine M, Kint A, Lachapelle JM, Tennstedt D. Halomethasone (C 48.401-Ba) for the Topical Treatment of Common Dermatoses. Journal of International Medical Research 1984;12(5):307-9. [EMBASE: 1984244422]
Dobrev 2003 {published data only}
  • Dobrev H, Zissova L, Yankova R. Study of four antidandruff shampoos therapeutic effectiveness [Abstract P25-7]. The 12th Congress of the European Academy of Dermatology and Venereology Barcelona, Spain 15-18th October 2003. Journal of the European Academy of Dermatology & Venereology 2003;17(Suppl 3):342.
Elewski 2009b {published data only}
Elie 1983 {published data only}
  • Elie R, Durocher LP, Kavalec EC. Effect of salicylic acid on the activity of betamethasone-17,21-dipropionate in the treatment of erythematous squamous dermatoses. Journal of International Medical Research 1983;11(2):108-12. [EMBASE: 1983129354]
Eun 2009 {published data only}
  • Eun HC. Clinical efficacies of topical agents for the treatment of seborrheic dermatitis on the scalp. 67th Annual Meeting of the American Academy of Dermatology, AAD San Francisco, CA United States. Conference Start: 20090306 Conference End: 20090310. Journal of the American Academy of Dermatology 2009;60(3 Suppl 1):AB47. [EMBASE: 70141908]
Franz 2000 {published data only}
Fredriksson 1975a {published data only}
  • Fredriksson T, Gip L, Hamfelt A. Investigations of a new synthetic steroid, betamethasone-17, 21-dipropionate, in alcoholic solution. Current Therapeutic Research, Clinical & Experimental 1975;18(2):324-31. [EMBASE: 0976132342]
Fredriksson 1985 {published data only}
  • Fredriksson T. Controlled comparison of Clinitar Shampoo and Selsun Shampoo in the treatment of seborrhoeic dermatitis of the scalp. British Journal of Clinical Practice 1985;39(1):25-8. [EMBASE: 1985059997]
Freeman 2002 {published data only}
  • Freeman S, Howard A, Foley P, Rosen R, Wood G, See J-A, et al. Efficacy, cutaneous tolerance and cosmetic acceptability of desonide 0.05% lotion (Desowen®) versus vehicle in the short-term treatment of facial atopic or seborrhoeic dermatitis. Australasian Journal of Dermatology 2002;43(3):186-9. [EMBASE: 2002259552]
Fritz 1995 {published data only}
  • Fritz K, Itschert G. Topical application of 8% Lithiumsuccinat and 0.05% Zincsulfate in seborrhoic Dermatitis. [Lokaltherapie des seborrhoischen Ekzems mit 0.05% Zinksulfat und 8% Lithiumsuccinat]. H + G Zeitschrift Fur Hautkrankheiten 1995;70:155-6.
Futterer 1981 {published data only}
  • Futterer E. Evaluation of efficacy of antidandruff agents. Journal of the Society of Cosmetic Chemists of Japan 1981;32(6):327-38. [EMBASE: 1982133716]
Gayko 2006 {published data only}
  • Gayko G, Warnecke J, Zelenkova H. The use of a pale type of Ichthyol in cosmetic dermatology. Cosmetic, single-centre, controlled and randomized double blind study for proof of efficacy and tolerance of a combination of Ichthyol Pale 0.5% and ketoconazole 0.5% vs. ketoconazole 1.0% shampoo in treatment of moderate to severe dandruff. Dermatologia Kliniczna 2006;8(4):243-7. [EMBASE: 2007006167]
Gentry 1973 {published data only}
Goffin 1996 {published data only}
  • Goffin V, Pierard-Franchimont C, Pierard GE. Antidandruff shampoos and the stratum corneum. Journal of Dermatological Treatment 1996;7(4):215-8. [EMBASE: 1997028593]
Gould 1988 {published data only}
  • Gould DJ, Davies MG, Kersey PJW, Kenicer K, Green C, Strong A, et al. Topical lithium succinate - a safe and effective treatment for seborrhoeic dermatitis in adults. International Pharmaceutical Abstracts British Journal of Dermatology 1988;119:27-8.
Grossman 1997 {published data only}
  • Grossman R, Gisoldi E, Phillips S, Cauwenbergh G. A comparative efficacy study of two dandruff shampoos [Abstract 1206]. The 19th World Congress of Dermatology 15-20 June, 1997 Sydney, Australia. Australasian Journal of Dermatology 1997;38(Suppl 2):94.
High 2006 {published data only}
  • High WA, Pandya AG. Pilot trial of 1% pimecrolimus cream in the treatment of seborrheic dermatitis in African American adults with associated hypopigmentation. Journal of the American Academy of Dermatology 2006;54(6):1083-8. [EMBASE: 2006227424]
Hochman 1988 {published data only}
  • Hochman HA, Schwartz SR. A comparison of two sulfur and salicylic acid shampoos in the treatment of dandruff. Current Therapeutic Research Clinical & Experimental 1988;44(6):1071-5. [EMBASE: 1989023984]
Humke 2002 {published data only}
  • Humke S, Budde MA, Richard A, Rougier A, Krutmann J. Efficacy and tolerability of a new shampoo in the treatment of dandruff [Abstract PO425]. 20th World Congress of Dermatology Paris 1st to 5th July 2002. Annales de Dermatologie et de Venereologie 2002;129:1S454.
Jacksonville 1969 {published data only}
  • Jacksonville Dermatology Society. Hydrocortisone Alcohol in the Treatment of Seborrheic Dermatitis. Cutis 1969;5(9):1130-2.
Jafferany 2008 {published data only}
  • Jafferany M. Lithium and skin: dermatologic manifestations of lithium therapy. International Journal of Dermatology 2008; Vol. 47, issue 11:1101-11. [EMBASE: 2008520868]
Jaramillo 1992 {published data only}
  • Jaramillo Antillón O, Hernández López J, Koon Rodríguez S, Rodríguez Vindas J, Freer Bustamante E. Comparative double-blind, randomized zinc pyrithion 1.5 shampoo in the treatment of dandruff [Estudio comparativo a doble ciego y aleatoria del zinc pyrithion al 1.5% en champu en el tratamiento de la caspa]. Revista Costarricense de Ciencias Medicas 1992;13(1/2):33-6.
Jensen 2009 {published data only}
  • Jensen J, Clausen C, Folster-Holst R, Proksch E, Poblete-Gutierrez P. Seborrheic eczema responds more quickly to treatment with pimecrolimus cream than treatment with ketoconazole cream. 36th Annual Meeting of the Arbeitsgemeinschaft Dermatologische Forschung, ADF Heidelberg Germany. Conference Start: 20090305 Conference End: 20090307. Experimental Dermatology 2009;18(3):302. [EMBASE: 70202963]
Jensen 2010 {published data only}
  • Jensen J-M, Clausen C, Brasch J, Brautigam M, Glaser R, Schwarz T, et al. Pimecrolimus Cream Treatment Normalizes Clinical Symptoms, Skin Barrier Function and Antimicrobial Protein Expression in Seborrheic Eczema. 40th Annual Meeting of the European Society for Dermatological Research Helsinki Finland. Conference Start: 20100908 Conference End: 20100911. Journal of Investigative Dermatology 2010;130(Issue S2):S69. [EMBASE: 70263800]
Kaminester 2002 {published data only}
  • Kaminester L, Bhagwat D. Clinical efficacy of a unique 10% sulfacetamide lotion in patients with seborrheic dermatitis of the scalp [Abstract P1982]. 20th World Congress of Dermatology Paris 1st to 5th July 2002. Annales de Dermatologie et de Venereologie 2002;129:1S758.
Karsono 2010 {published data only}
  • Karsono JK, Kerr K, Darcy T, Henry J, Mizoguchi H, Schwartz J, et al. New innovations in anti-dandruff technology: Proteomics application [Abstract]. 1st Eastern Asia Dermatology Congress, EADC2010 Fukuoka Japan. Conference Start: 20100930 Conference End: 20101003. Journal of Dermatology 2010;37:97. [EMBASE: 70284716]
Kim 2012 {published data only}
  • Kim TW, Jwa SW, Song M, Kim HS, Ko HC, Kim MB, et al. How frequently should 0.1% tacrolimus ointment be used to reduce exacerbation of stabilised adult facial seborrhoeic dermatitis? Results from a randomised, double-blind, vehicle-controlled, multi-centre trial [Abstract]. 2nd Eastern Asia Dermatology Congress Beijing China. Conference Start: 20120613 Conference End: 20120615. Journal of Dermatology 2012;39(Suppl):19. [EMBASE: 70800535]
Kim 2013 {published data only}
  • Kim TW, Mun JH, Jwa SW, Song M, Kim HS, Ko HC, et al. Proactive treatment of adult facial seborrhoeic dermatitis with 0.1% tacrolimus ointment: randomized, double-blind, vehicle-controlled, multi-centre trial. Acta Dermato-Venereologica 2013;93(5):557-561. [EMBASE: 2013558915]
Kircik 2009 {published data only}
  • Kircik L. An open-label, single-center pilot study to determine the antifungal activity of a new nonsteroidal cream (Promiseb Topical Cream) after 7 days of use in healthy volunteers. Clinics in Dermatology 2009;27(6 Suppl):S44-7. [EMBASE: 19878780]
Levy 1974 {published data only}
  • Levy J, Highly FM Jr. Double-Blind Trial of a New Topical Corticosteroid in a US Naval Hospital. Military Medicine 1974;139(9):728-30. [EMBASE: 0975135470]
Li 2000 {published data only}
  • Li FC, Liu F, Wang XL. Observations to the curative effects in the treatment of 120 cases of seborrhoeic dermatitis and pityriasis capitis with triatop and coal tar lotion. Journal of Clinical Dermatology 2000;29:290.
Lin 2010 {published data only}
López Padilla 1996 {published data only}
  • López Padilla S, Carvajal A. Ketoconazole 1% shampoo vs climbazole shampoo on the treatment of seborrhoeic dermatitis in scalp skin [Ketoconazol al 1 por ciento champú vs. climbazole champú en el tratamiento de la dermatitis seborreica en piel cabelluda]. Dermatología Revista Mexina 1996;40(3):190-5.
Luo 1993 {published data only}
  • Luo QL, Shun GX, Wu XG, Li S, Tang Z. The clinical observation of 901 cases multi-effective lotion for scalp steatorrhea dermatitis (Chinese). Chinese Journal of Dermatovenereology 1993;7(2):98-9.
Marks 1974 {published data only}
  • Marks R, Bhogal B, Wilson L. The effect of betamethasone valerate on seborrhoeic dermatitis of the scalp. A clinical, histopathological and cell kinetic study. Acta Dermato-Venereologica 1974;54(5):373-5. [EMBASE: 0975122569]
Mensing 2008 {published data only}
  • Mensing CO, Mensing CH, Mensing H. Treatment with pimecrolimus cream 1% clears irritant dermatitis of the periocular region, face and neck. International Journal of Dermatology 2008; Vol. 47, issue 9:960-4. [EMBASE: 2008402864]
Nolting 1983 {published data only}
  • Nolting S, Hagemeier HH. Betamethasone-17,21-dipropionate plus salicylic acid compared with betamethasone-dipropionate solution in the therapy of erythemato-squamous dermatoses [Therapie erythrosquamoser Dermatosen. Betamethason-Dipropionat plus Salizylsaure im Vergleich zu Betamethason-Dipropionat-Losung]. Fortschritte der Medizin 1983;101(37):1679-83. [EMBASE: 6227542]
Nolting 1985 {published data only}
  • Nolting S. Treatment with topical corticosteroids in severe or resistant dermatoses [Behandlung mit Kortikosteroid-Externa bei schweren oder resistenten Dermatosen]. Dermatosen in Beruf und Umwelt 1985;33(4):140-4. [EMBASE: 1985211204]
Pierard-Franchimont 1995 {published data only}
  • Pierard-Franchimont C, Pierard P. Subjects using anti-dandruff shampoos. Journal of the European Academy of Dermatology & Venereology 1995;5(Suppl 1):S153.
Pierard-Franchimont 1999 {published data only}
  • Pierard-Franchimont C, Henry F, Uhoda I, Pierard GE. Comparative anti-dandruff efficacy between a tar and a non-tar shampoo. Journal of the European Academy of Dermatology & Venereology 1999;12:S305.
Pierard-Franchimont 2000 {published data only}
Pierard-Franchimont 2002a {published data only}
  • Pierard-Franchimont C, Goffin V, Henry F, Uhoda I, Braham C, Pierard GE. Nudging hair shedding by antidandruff shampoos. A comparison of 1% ketoconazole, 1% piroctone olamine and 1% zinc pyrithione formulations. International Journal of Cosmetic Science 2002;24(5):249-56. [EMBASE: 2002427181]
Pierard-Franchimont 2002b {published data only}
  • Pierard-Franchimont C, Pierard GE. A double-blind placebo-controlled study of ketoconazole + desonide gel combination in the treatment of facial seborrheic dermatitis. Dermatology 2002;204(4):344-7. [EMBASE: 2002222909]
Pierard-Franchimont 2002c {published data only}
  • Pierard-Franchimont C, Goffin V, Decroix J, Pierard GE. A multicenter randomized trial of ketoconazole 2% and zinc pyrithione 1% shampoos in severe dandruff and seborrheic dermatitis. Skin Pharmacology & Applied Skin Physiology 2002;15(6):434-41. [EMBASE: 2003001937]
Reiffenstuhl 1973 {published data only}
  • Reiffenstuhl B, Wolf D. Clinical experiences with fluocinonide FAPG [Klinische Erfahrungen mit Fluocinonid FAPG]. Wiener Medizinische Wochenschrift 1973;123(38):555-6. [EMBASE: 4270843]
Reinhard 1974 {published data only}
  • Reinhard W, Weber G, Petres J. Comparative studies with halcinonide and fluocortolone in local administration [Vergleichende Untersuchungen mit Halcinonid und Fluocortolon bei lokaler Applikation]. Zeitschrift für Hautkrankheiten 1974;49(7):267-72. [EMBASE: 4275779]
Sohn 1978 {published data only}
  • Sohn HS, Kim YP. A Study on the Effectiveness of Clocortolone Pivalate (Purantix®) Cream on Certain Common Skin diseases. Korean Journal of Dermatology 1978;16(4):311-7. [EMBASE: 0979011221]
Tomoka 1973 {published data only}
  • Tomoka MT, Ochoa AG. Clinical effectiveness of fluocinonide in several skin diseases [Klinische Wirksamkeit des Fluocinonid bei verschiedenen Dermatosen]. Wiener medizinische Wochenschrift 1973;123(15):247-8. [EMBASE: 4267190]
Turnbull 1982 {published data only}
  • Turnbull BC. Locoid vs Betnovate lotion in the treatment of seborrhoeic and atopic dermatitis of the scalp. New Zealand Medical Journal 1982;95(718):738-40. [EMBASE: 1983057047]
Veien 1980 {published data only}
Wacker 1989 {published data only}
  • Wacker KH. Treatment of seborrhoeic dermatitis and other disorders of the scalp requiring corticosteroids using alclometasone dipropionate 0.05% solution. Results of a double-blind-study [DELONAL LOSUNG (ALCLOMETASONDIPROPIONAT 0,05%) BEI SEBORRHOISCHEM KOPFEKZEM UND ANDEREN KORTIKOIDBEDURFTIGEN KOPFHAUTERKRAMKUNGEN. ERGEBNISSE EINER DOPPELBLINDSTUDIE]. Aktuelle Dermatologie 1989;15(3):84-7. [EMBASE: 1989080414]
Weiss 2011 {published data only}
  • Weiss S, Raton B, Wyres M, Brundage T. A novel foam vehicle is consistently preferred by patients for dermatologic conditions [Abstract]. 69th Annual Meeting of the American Academy of Dermatology New Orleans, LA United States. Conference Start: 20110204 Conference End: 20110208. Journal of the American Academy of Dermatology 2011;64(2 Suppl 1):AB50. [EMBASE: 70331516]
Wollina 2006 {published data only}
Wollina 2007 {published data only}
  • Wollina U. The role of topical calcineurin inhibitors for skin diseases other than atopic dermatitis. American Journal of Clinical Dermatology 2007;8(3):157-73. [EMBASE: 2007314620]
Yawalkar 1983 {published data only}
  • Yawalkar SJ, Macarol V, Montanari C. An Overview of International Clinical Trials with Halometasone Cream. Journal of International Medical Research 1983;11(Suppl 1):1-7. [EMBASE: 1983071917]

References to studies awaiting assessment

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
Fredriksson 1975b {published data only}
  • Fredriksson T. Treatment of seborrheic dermatitis: double-blind studies comparing dexamethasone 0.012% and fluocinolone acetonide 0.01%. Cutis 1975;15(5):765-8. [EMBASE: 0976065942]
Snyder 1969 {published data only}
  • Snyder BL. A double blind evaluation of fluocinolone acetonide solution in the treatment of seborrheic dermatitis of the face. Pennsylvania Medicine 1969;72(6):68-9. [EMBASE: 4239005]

References to ongoing studies

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
EudraCT 2005-006208-21 {published data only}
  • 2005-006208-21. Clinical Efficacy of Pimecrolimus Cream in Seborrheic Dermatitis. Efficacy of pimecrolimus in normalizing clinical symptoms, explorative study of barrier function, hydration, lipid content and differentiation in seborrheic dermatitis: a randomized, double-blind study in adults with seborrheic dermatitis treated with 1 % pimecrolimus cream versus 2 % ketoconazole cream as control. www.clinicaltrialsregister.eu/ctr-search/search?query=eudract_number:2005-006208-21 (accessed 28 May 2013).
EudraCT 2006-003984-30 {published data only}
  • 2006-003984-30. A multicenter, randomized, double-blind, two-arm, vehicle-controlled, parallel-group, two stage study to evaluate and demonstrate the efficacy and to evaluate the safety of pimecrolimus 1% cream in the treatment of seborrhoeic dermatitis in patients 12 years of age and older. www.clinicaltrialsregister.eu/ctr-search/search?query=eudract_number:2006-003984-30 (accessed 28 May 2013).
EudraCT 2007-007088-25 {published data only}
  • 2007-007088-25. Inflammatory seborrhoeic dermatitis of the scalp in adult. www.clinicaltrialsregister.eu/ctr-search/search?query=2007-007088-25 (accessed 28 May 2013).
EudraCT 2009-013120-23 {published data only}
  • 2009-013120-23. Efficacy and safety of LBC 45 (lithium gluconate) for the treatment of seborrhoeic dermatitis of the scalp [Efficacité et tolérance du LBC 45 dans la dermite séborrhéique du cuir chevelu]. www.clinicaltrialsregister.eu/ctr-search/search?query=2009-013120-23 (accessed 28 May 2013).
EudraCT 2010-022861-93 {published data only}
  • 2010-022861-93. Confirmation of th efficacy and safety of LBC 45 (lithium gluconate) for the treatment of seborrhoeic dermatitis of the scalp [Confirmation de l'efficacité et de la tolérance du LBC 45 dans la dermite séborrhéique du cuir chevelu]. www.clinicaltrialsregister.eu/ctr-search/search?query=2010-022861-93 (accessed 28 May 2013).
NCT00403559 {published data only}
  • NCT00403559. A 4 Week Study of Elidel for the Treatment of Seborrheic Dermatitis. clinicaltrials.gov/ct2/show/NCT00403559 (accessed 28 May 2013).
NCT01011621 {published data only}
  • NCT01011621. Efficacy and Tolerability of Prednisolone Acetate 0.5% Cream Versus Betamethasone Valerate 0.1% Cream in Cortisosensitive Dermatosis. clinicaltrials.gov/ct2/show/study/NCT01011621 (accessed 28 May 2013).

Additional references

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. What's new
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Notes
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
Ang-Tiu 2012
  • Ang-Tiu C, Maghrajani C, Maano C. Pimecrolimus 1% cream for the treatment of seborrheic dermatitis: a systematic review of randomized controlled trials.. Expert Review of Clinical Pharmacology 2012;5(1):91-7. [EMBASE: 2011676752]
Burton 1983
Del Rosso 2011
  • Del Rosso JQ. Adult Seborrheic Dermatitis: A Status Report on Practical Topical Management. The Journal of Clinical and Aesthetic Dermatology 2011;4(5):32-8. [PUBMED: 21607192 ]
Foley 2003
  • Foley P, Zuo Y, Plunkett A, Merlin K, Marks R. The frequency of common skin conditions in pre-school-aged children in Australia: seborrheic dermatitis and pityriasis capitis (cradle cap). Archives of Dermatology 2003;139(3):318-22. [MEDLINE: 12622623]
Gupta 2004
Halder 2003
Higgins 2011
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. Available from www.cochrane-handbook.org.
Kim 2010
  • Kim D, Lockey R. Dermatology for the allergist. World Allergy Organization Journal 2010;3(6):202-15. [MEDLINE: 23268431]
Naldi 2009
Okokon 2011
Schwartz 2006