Successful treatment and prophylaxis of scalp seborrhoeic dermatitis and dandruff with 2% ketoconazole shampoo: results of a multicentre, double-blind, placebo-controlled trial

Pityrosporum ovale appears to play an important role in the pathogenesis of seborrhoeic dermatitis. Ketoconazole is an antimycotic agent with a high in vitro and in vivo efficacy against P. ovale. We performed a multicentre study to investigate the efficacy of ketoconazole 2% shampoo in the treatment and prophylaxis of seborrhoeic dermatitis and dandruff. Five hundred and seventy-five patients presenting with moderate to severe seborrhoeic dermatitis and dandruff of the scalp were treated with 2% ketoconazole shampoo twice weekly for 2–4 weeks, producing an excellent response in 88%. Of those patients who responded, 312 were included in a prophylactic phase, lasting 6 months. These patients were treated with the active preparation (shampoo containing 2% ketoconazole) once-weekly, once every other week, alternating with placebo (shampoo without ketoconazole), or with placebo only once-weekly. Forty-eight (47%) patients in the placebo group experienced a relapse of seborrhoeic dermatitis, compared with 23 (19%) patients in the active treatment group, and 31 (31%) patients in the active/placebo group. The medication was well tolerated in all three groups. We conclude that ketoconazole 2% shampoo is highly effective, not only in clearing scalp seborrhoeic dermatitis and dandruff, but also in preventing relapse of the disease when used prophylactically once weekly.     

Effects of Pityrosporum ovale on proliferation,immunoglobulin (IgA,G, M) synthesis and cytokine (IL-2, IL-10, IFNγ) production of peripheral blood mononuclear cells from patients with seborrhoeic dermatitis

The aetiology of seborrhoeic dermatitis (SD) is still unknown. An increased number ofPityrosposurm ovale in lesional skin of patients with SD has been suggested to play a crucial role in the pathogenesis of the disease since double-blind trials with antifungal drugs (e.g. ketoconazole) have shown that these agents result in a significantly reduced disease intensity. The frequent association of HIV infection and SD may be due to a suppressed cell-mediated immunity. In order to characterize the role of the humoral and cellular immune response in patients with SD the effects of aP. ovale extract on the proliferation of, and interleukin-2 (IL-2), IL-10 by an interferon-γ (IFNγ) production, and immunoglobulin (IgA, IgG, IgM) synthesis by peripheral blood mononuclear cells (PBMC) from patients with SD were studied in vitro. Healthy volunteers served as controls. PBMC from normal donors responded with a significantly increased proliferation toP. ovale antigen, whereas cells from patients with SD did not. Additionally, IL-2 and IFNγ production by PBMC from patients with SD was markedly depressed compared with normal cells after stimulation withP. ovale. However, stimulation of PBMC from SD patients withP. ovale antigen induced significantly increased IL-10 synthesis. IgA, IgG and IgM synthesis was significantly increased in cultures of PBMC from patients with SD whether the cells were antigen-stimulated or not. Our results support the assumption that strong skin colonization withP. ovale in SD is due to an altered cellular immunity, which may be induced by increased IL-10 secretion.     

The evaluation of various methods and antigens for the detection of antibodies against Pityrosporum ovale in patients with seborrhoeic dermatitis

Sera from 10 patients with seborrhoeic dermatitis and from 10 age-matched healthy individuals were examined for IgG activity against Pityrosporum ovale. The IgG activity was analysed using the following techniques: an enzyme-linked immunosorbent assay (ELISA) against whole P. ovale cells, purified cell-wall carbohydrate or protein extract, an indirect slide-immunofluorescence assay and fluorescence-activated flow cytometry using the whole organism as antigen. The ELISA method using the protein antigen was the only technique that showed a significant difference between patients and controls; a lower antibody response was found in the seborrhoeic dermatitis patients compared to healthy controls.     

Antibodies to proteins from Pityrosporum ovale in the sera from patients with psoriasis

In order to analyse the humoral immune response to the commensal yeast Pityrosporum ovale, we developed a western immunoblot technique with a salt soluble extract of P. ovale cytoplasm. In the present study, we tested sera from patients with psoriasis (n= 15), seborrhoeic dermatitis (n= 10), pityriasis versicolor (n= 8), and normal controls (n = 10). Seventy-three per cent (11/15) of the patients with psoriasis showed specific reactivity with a protein derived from P. ovale of estimated molecular mass 120 kDa, and 46% (7/15) of the cases recognized a 100-kDa protein. Sera from pityriasis versicolor and normal donors showed nonspecific reactivity with several bands of lower molecular weight. To characterize the location of the 100 and 120-kDa proteins, we performed a lyticase digestion of the cell wall, and analysed the soluble digested products by western blotting. The sera from psoriasis patients detected several bands in the range 100–120 kDa. The finding of the immunoreactive 120-kDa protein in this fraction suggests its location at the space between cell wail and membrane (periplasmic space). As a control, we performed an extraction of the cytoplasmic proteins of the dimorphic yeast Candida albicans. C. albicans showed a different pattern of banding in SDS–PAGE. Immunoblots with C. albicans did not allow the detection of any related band. A smear was observed in the high molecular weight range consistent with the presence of lipopolysaccharides. The role of the immune response in infection by P. ovale has not yet been fully explored. The function of the antibodies recognizing 100-120-kDa bands in the majority of the patients with psoriasis seems to represent a specific immune response to the yeast phase of P. ovale.     

Seborrhoeic dermatitis and Pityrosporum ovale: a cultural and immunological study

Seborrhoeic dermatitis is associated with Pityrosporum ovale, but the exact role of the organism is not clarified. In order to study this connection we have investigated 30 patients with seborrhoeic dermatitis with quantitative culture for P. ovale, serum IgG antibodies against P. ovale and lipid measurements. We compared the patients with 60 healthy individuals and found no significant difference in the number of P. ovale or serum antibodies. The lipid content on the skin was significantly higher in the patient group (p = 0.0001). There was no difference in the number of P. ovale in lesions compared to healthy skin in the patient group. This study support our theory that an abnormal reaction in the skin to P. ovale causes the inflammation and the number of P. ovale is of minor importance.     

The prevalence of Malassezia yeasts in patients with atopic dermatitis, seborrhoeic dermatitis and healthy controls

Cultures for Malassezia yeasts were taken from both normal-looking skin and lesional skin in 124 patients with atopic dermatitis, 16 patients with seborrhoeic dermatitis and from normal skin of 31 healthy controls. Positive Malassezia growth was found in fewer patients with atopic dermatitis (56%) than in patients with seborrhoeic dermatitis (88%) or in healthy controls (84%, p<0.01). In the patients with atopic dermatitis, fewer positive cultures were found in lesional (28%) than in non-lesional skin (44%, p<0.05), while positive cultures were found in 75% of both lesional and non-lesional skin of patients with seborrhoeic dermatitis (not significant). M. sympodialis dominated in patients with atopic dermatitis (46%) and in healthy controls (69%). In patients with seborrhoeic dermatitis both M. sympodialis and M. obtusa were cultured in 43%. A Malassezia species extract mixture would increase the possibility of detecting IgE sensitization to Malassezia in patients with atopic dermatitis.     

A pilot study on the efficacy of mometasone furoate fatty cream on clinical parameters, time to relapse and microbial flora in atopic dermatitis

Aim To study the antimicrobial effect in vitro of hexylene glycol and mometasone furoate fatly cream (contains 12% hexylene glycol) and to study the effect of mometasone furoate fatty cream on clinical parameters and microbial flora in patients with atopic dermatitis. Methods The effect of hexylene glycol and mometasone furoate fatty cream against Staphylococcus aureus, S. epidermidis, Pityrosporum ovule and Candida albicans was studied in vitro. Twenty patients with moderate to severe atopic dermatitis were treated with mometasone furoate 0.1 % fatty cream once daily for 3 weeks and then intermittently for 3 weeks. Quantitative cultures for bacteria and fungi were taken at baseline, during treatment and 4 weeks after end of treatment. Results Both hexylene glycol and mometasone furoate fatty cream were effective in vitro against the studied microorganisms. Thirteen of 18 patients who returned for control were cleared after 3 weeks of treatment and 15/18 patients or 83% were cleared after 6 weeks. Four weeks after end of treatment only one patient remained cleared. However, 11/14 patients who returned for this control were still improved compared to baseline. S aureus was cultured in 16/20 patients at baseline but in only 7/18 patients after 6 weeks of treatment. The number of S. aureus dropped significantly but increased two-fold 4 weeks after end of treatment. The number of cultured P. ovale was also significantly reduced after 6 weeks. Conclusion This study clearly demonstrate the good effect of mometasone furoate fatty cream, which contains 12% hexylene glycol, in the treatment of atopic dermatitis paralleled by a significant reduction in the number of S. aureus and P. ovale.     

In vitro susceptibility testing of Pityrosporum ovale against antifungal, antiseborrheic and antipsoriatic agents

Objective The in vitro antimicrobial susceptibility of Pityrosporum ovale strains isolated from patients with seborrheic dermatitis was determined. Method Minimum inhibitory concentrations of a total of 11 agents - including true antifungal, antiseborrheic, and antipsoriatic drugs - were measured. Results Ketoconazole was the most effective of the tested antifungal agents against Pityrosporum ovale in vitro (minimum inhibitory concentration 0.1 μg/ml). The antiseborrheic agents zinc pyrithione and selenium disulfide showed a good in vitro efficacy against Pityrosporum with similar minimum inhibitory concentrations. Liquor carbonis detergens and dithranol were also able to inhibit growth of Pityrosporum ovale in vitro, but much higher concentrations were necessary. Conclusion The tested agents commonly used against seborrheic dermatitis might exert their efficacy, at least in part, due to inhibition of Pityrosporum ovale.     

An immunological study in patients with seborrhoeic dermatitis

The humoral and cellular immune-status was studied in 30 patients with seborrhoeic dermatitis. Increased frequencies of natural killer cells were found in 46% of patients. Furthermore, subnormal mitogen stimulation responses were demonstrated in 13 patients, whereas two individuals were found to have very high numbers of activated T lymphocytes in peripheral blood. Higher-than-normal total serum IgG and IgA was observed in 14 and 11 patients, respectively. For nine of 12 patients with skin lesions, dermal perivascular cell infiltrates were seen. The majority of the infiltrating cells reacted with anti-CD4 antibodies. HLA-DR-expressing keratinocytes were found in two biopsies. The study suggests that patients with seborrhoeic dermatitis may have depressed T-cell function. This could have a bearing on their susceptibility to the Pityrosporum ovale-associated dermatitis. The very high frequencies of activated T cells observed in the peripheral blood of two otherwise healthy seborrhoeic individuals suggests that intermittent systemic immune activation may occur. Seborrhoeic dermatitis is a common skin disease. It can be diagnosed by its characteristic red to yellow-brown lesions covered with greasy scales distributed in areas with a high number of sebaceous glands, such as the scalp, face and upper trunk. There is an association between seborrhoeic dermatitis and the lipophilic yeast Pityrosporum ovale but its exact aetiological role is not known. The yeast is a member of the normal cutaneous flora but also the aetiological agent of pityriasis versicolor and Pityrosporum folliculitis. P. ovale can activate complement via the direct and alternative pathways. This may play some part in the induction of inflammation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ketoconazole in atopic dermatitis: therapeutic response is correlated with decrease in serum IgE

The prevalence of specific IgE antibodies to the yeasts Pityrosporum orbiculare and Candida albicans was investigated in adult patients with atopic dermatitis (AD) or with seborrhoeic dermatitis and in healthy controls by means of the radioallergosorbent test (RAST). Of 63 AD patients, 28 (44%) had IgE antibodies to P. orbiculare and 21 (33%) to C. albicans. This is highly significant, since no antibodies were found in sera from other patients or controls. With the intention to treat, 20 patients with AD and a positive RAST to P. orbiculare were given ketoconazole 200 mg daily for 2 months and 200 mg twice weekly for further 3 months. The clinical scores improved during treatment with a reduction in the levels of specific IgE to P. orbiculare and total serum IgE. However, there were no correlations between clinical score and serum levels of P. orbiculare-specific IgE. C. albicans-specific IgE, on the other hand, correlated both with clinical score and with total serum IgE.     

Seborrhoeic dermatitis is not caused by an altered immune response to Malassezia yeast

The immune response of patients with seborrhoeic dermatitis and healthy age- and sex-matched controls was examined to test the hypothesis that an inadequate or inappropriate immune response to Malassezia yeast leads to seborrhoeic dermatitis. Antibody responses were examined using enzyme-linked immunosorbent assays (ELISAs) and Western blots and lymphocyte responses using lymphocyte proliferation assays. The level of IgG and IgM specific for whole yeast cells or extracted proteins of two isolates of M. furfur was tested in ELISA. A wide range of antibody levels was found but the patient and control groups were indistinguishable ( n  = 19), and the groups could not be distinguished by the pattern of Malassezia proteins recognized by their sera in Western blots. The average affinity of the subjects' antibodies specific for Malassezia cells or proteins was measured using ammonium thiocyanate dissociation. Most of the sera had moderate affinities corresponding to 50% dissociation at thiocyanate concentrations of 0.5–1.0 mol/L. There was no difference between patients and matched controls. The proliferation of the patients' lymphocytes in response to a number of M. furfur cell preparations was measured: whole cells, cytoplasmic proteins, cell walls, soluble molecules extracted from the cell walls using sonication, and a commercial preparation. There was a wide range of responses between individuals, but there was no difference between the three groups: patients with seborrhoeic dermatitis ( n  = 16), healthy controls ( n  = 16) and a group suffering from other inflammatory skin conditions ( n  = 15). The results do not support the hypothesis that an inadequate immune response to Malassezia yeast could lead to seborrhoeic dermatitis. Other possible pathological mechanisms include toxin production or lipase activity.     

Topical lithium succinate ointment (Efalith) in the treatment of AIDS-related seborrhoeic dermatitis

A randomised, double-blind, placebo-controlled trial with lithium succinate ointment was conducted in patients with UDS-associated facial seborrhoeic dermatitis. Twice daily applications of the ointment brought about a rapid (2-.S days) and highly significant (P= 0·007) improvement in the severity of the condition. Lithium succinate ointment is well tolerated and can be a useful treatment for seborrhoeic dermatitis in this group of patients.     

Seborrhoeic dermatitis and Pityrosporum (Malassezia) folliculitis: characterization of inflammatory cells and mediators in the skin by immunohistochemistry

BACKGROUND: The fact that Pityrosporum ovale plays a part in seborrhoeic dermatitis is well established but the mechanism of this relationship has not been established. OBJECTIVES: To compare the number and type of inflammatory cells and mediators in skin biopsies from normal and lesional skin from the trunk and scalp in patients with seborrhoeic dermatitis, Pityrosporum (Malassezia) folliculitis and in normal skin from healthy controls. METHODS: The skin biopsies were stained using the labelled Streptavidin-biotin METHOD: The following markers were studied: CD4, CD8, CD68, HLA-DR, NK1, CD16, C1q, C3c, IgG, CD54 (ICAM-1), interleukin (IL) -1alpha, IL-1beta, IL-2, IL-4, IL-6, IL-10, IL-12, tumour necrosis factor-alpha and interferon-gamma. RESULTS: HLA-DR+ cells were seen in the highest number, and were higher in lesional skin compared with normal skin from both patients and healthy volunteers. ICAM-1 expression was also increased in lesional skin. C1q and the interleukins showed an increased cellular and intercellular staining in patients compared with healthy controls and the intercellular staining was often more intense in lesions compared with non-lesional skin. Staining was often more intense when Malassezia (Pityrosporum ovale) yeast cells were present. CONCLUSIONS: An increase in NK1+ and CD16+ cells in combination with complement activation indicates that an irritant non-immunogenic stimulation of the immune system is important. The result with the interleukins showed both an increase in the production of inflammatory interleukins as well as in the regulatory interleukins for both TH1 and TH2 cells. Similarities to the immune response described for Candida albicans infections indicate the role of Malassezia in the skin response in seborrhoeic dermatitis and Pityrosporum folliculitis.     

Seborrhoeic Dermatitis: Treatment with Anti-Mycotic Agents

In order to elucidate the effectiveness of anti-mycotics in treating seborrhoeic dermatitis, an attempt was made to isolate Malassezia from seborrhoeic lesions of patients of seborrhoeic dermatitis. The results revealed that, in male patients, 46/49 cases were positive for Malassezia furfur on the face and 30/48 cases were positive for M. furfur on the scalp. In female patients, 7/13 cases were positive for M. furfur on the face, and 6/17 cases were positive for M. furfur on the scalp. Anti-mycotic agents were excellent in 50% and good in 31% of the spore-positive cases, yielding an overall efficacy rate of 81%. In contrast, the treatment of the face with vehicle alone showed only one excellent result out of 8 cases. Although clinical improvement was rapid on the side treated with a topical corticosteroid in the half-side-test, numerous fungal elements remained. While the improvement with anti-mycotic agents was slower than that with the corticosteroid, clinical improvement became evident by the third week of administration and fungal elements disappeared.     

Differential T-cell reactivity to the round and oval forms of Pityrosporum in the skin of patients with psoriasis

Pityrosporum yeasts have been implicated as a trigger for the initiation of scalp lesions in psoriasis. To determine whether Pityrosporum-reactive T cells are present in lesional psoriatic skin. T-cell lines (TCL) were cultured from the scalps of nine patients with psoriasis and seven with alopecia areata (disease controls), and from non-scalp lesions from six of the psoriatic patients. The psoriatic skin TCL were stained for CD3, CD4, CD8 and TCR αβ expression and tested in a proliferation assay with Candida albicans and purified protein derivative (PPD), and cytoplasmic and cell-wall extracts of P. ovale (oval) and P.orbiculare (round). The proliferative responses of corresponding peripheral blood mononuclear cells (PBMC) were also determined. All the PBMC samples responded to the Pityrosporum extracts to variable extents, but no significant difference in the response of the group to the two different forms of yeast was observed. The response was mediated by CD4⁺ T cells and inhibited by the addition of anti-HLA-DR antibody. In addition, all nine psoriatic scalp TCL, which were predominately CD3⁺, CD4⁺ TCR αβ⁺, responded to the cytoplasmic, and five of nine TCL to the cell-wall extract of P. orbiculare. In contrast, only three of the nine TCL proliferated to either extract of P. ovale. This difference was significant for both the cytoplasmic (P < 0.01) and cell wall (P = 0.01) extracts. Similarly, the TCL cultured from non-scalp psoriatic lesions also showed a more marked response to the P. orbiculare extracts (P = 0.05). Furthermore, four of seven and two of seven scalp TCL from lesions of alopecia areata responded to the P. orbiculare and P. ovale extracts, respectively; these responses did not differ significantly from those of the psoriatic scalp TCL. None of the skin TCL responded to either Candida albicans or PPD. These findings demonstrate that T cells with differential reactivity to the round and oval forms of Pityrosporum are present in, but are not specific for, psoriatic skin lesions. A role for these cells in the pathogenesis of psoriasis remains speculative.     

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

Background Topical antifungals and corticosteroids are the mainstay of treatment for seborrhoeic dermatitis. The short‐contact clobetasol propionate 0·05% shampoo (CP) is an efficacious and safe once‐daily treatment for scalp psoriasis. Objectives To evaluate the efficacy and safety of CP alone and combined with ketoconazole shampoo 2% (KC) in the treatment of moderate to severe scalp seborrhoeic dermatitis. Methods This randomized and investigator‐blinded study consisted of three phases, each lasting 4 weeks. During the treatment phase, subjects were randomized to receive KC twice weekly (K2), CP twice weekly (C2), CP twice weekly alternating with KC twice weekly (C2 + K2) or CP four times weekly alternating with KC twice weekly (C4 + K2). All subjects received KC once weekly during the maintenance phase and were untreated during the follow‐up phase. Results At the end of the treatment phase, all three CP‐containing regimens were significantly more efficacious than K2 in decreasing the overall disease severity (P < 0·05). Both combination regimens were also significantly more efficacious than K2 in decreasing each individual sign of the disease (P < 0·05). While the C2 and C4 + K2 groups experienced slight worsening during the maintenance phase, the efficacy of C2 + K2 was sustained and remained the highest among all groups. All regimens were well tolerated without inducing any skin atrophy. Similarly low incidences of telangiectasia, burning and adverse events were observed among the four groups. Conclusions The combination therapy of twice‐weekly CP alternating with twice‐weekly KC provided significantly greater efficacy than KC alone and a sustained effect in the treatment of moderate to severe scalp seborrhoeic dermatitis.     

The carriage of Malassezia furfur serovars A, B and C in patients with pityriasis versicolor, seborrhoeic dermatitis and controls

The aetiological role of Malassezia furfur in various dermatoses is controversial. The role of the three serovars of M. furfur in Malassezia-associated diseases has not been investigated. This study measured population densities of M. furfur serovars A. Band C. propionibacteria and Micrococcaceae on the chest, back, forehead, left and right cheeks of 10 patients with pityriasis versicolor, and 10 age- and sexmatched controls: and 10 patients with seborrhoeic dermatitis, and 10 age- and sex-matched controls. The population densities of M. furfur. propionibacteria and Micrococcaceae did not vary at a given site between patients and the corresponding control subjects. Malassezia furfu serovar A was found to be the predominant isolate on the chest and back of all four groups. but there was no difference in the distribution of serovars on the forehead and cheeks. No serovar was specifically associated with lesional skin in either disease. Thus, this data indicated that there was no difference in either the total population density of M. furfur or the distribution of serovars on lesional skin compared with control skin in either pityriasis versicolor or seborrhoeic dermatitis.     

Phospholipase activity after β‐endorphin exposure discriminates Malassezia strains isolated from healthy and seborrhoeic dermatitis skin

Background Phospholipase activity and its induction by β‐endorphin have been associated with pathogenic Malassezia pachydermatis animal isolates. Objective To evaluate Malassezia phosholipase activity in human isolates from seborrhoeic dermatitis (SD) and healthy controls before and after β‐endorphin exposure. Methods Eighty‐four volunteers with or without SD (N = 41) were sampled. Isolated Malassezia strains were incubated in Dixon’s medium with and without 100 nmol/L β‐endorphin. Subsequently, phospholipase activity was assessed in egg‐yolk agar and the results were compared employing Wilcoxon sign test for paired data, chi‐squared test and multinomial logistic regression analysis. Results A total of 64 Malassezia strains were isolated. SD strains tended to have decreased phospholipase activity before (P = 0.057) and increased after exposure to β‐endorphin (P = 0.061) compared to isolates from healthy skin. Phospholipase activity after β‐endorphin exposure related to basal enzyme activity as a measure of per strain phospholipase inducibility by β‐endorphin did not depend on Malassezia species (P = 0.652). However, this latter biochemical trait discriminates strains isolated from SD lesional and healthy skin (P = 0.036). Conclusion β‐endorphin exposure modifies the in vitro phosholipase activity in Malassezia species isolated from SD lesional skin. This is in accordance with emerging evidence that enhanced local lipase activity is involved in the pathogenesis of SD.     

Cell-mediated immunity to Malassezia furfur in patients with seborrhoeic dermatitis and pityriasis versicolor

The lymphocyte transformation response to Malassezia furfur, Candida albicans, phytohaemagglutinin, concanavlin A and tuberculin purified protein derivative of 12 patients with pityriasis versicolor, 15 patients with seborrhoeic dermatitis and matched controls, was studied. Patients with pityriasis versicolor showed a significantly lower response to M. furfur than patients with seborrhoeic dermatitis and controls.     

The response of seborrhoeic dermatitis to ketoconazole

A randomized double-blind placebo-controlled cross-over study was made of ketoconazole 200 mg daily in nineteen patients with seborrhoeic dermatitis. All had scalp lesions and sixteen had seborrhoeic dermatitis at other sites. Responses were measured by clinician and patients independently, using a linear analogue scale. Body and scalp lesions and itch regressed considerably and significantly with ketoconazole in all but five patients, three of whom subsequently responded to a higher dose. The patients studied with seborrhoeic dermatitis had been sent by their family doctors in answer to a request for patients with dandruff, and the clinical difference between the two was found to be only of degree. Three patients with dandruff without erythema were studied separately using the same study design: all three responded similarly to those with seborrhoeic eczema. It is concluded that Pityrosporum yeast infection is the immediate cause of seborrhoeic dermatitis and that dandruff is its mildest manifestation.