What therapies do you recommend for patients with recalcitrant seborrheic dermatitis?

Topical roflumilast is easily the most effective thing I've ever seen. Prior to that being available, here were the go-to drugs for difficult seb derm:

1. Itraconazole 200 mg qd until better, then 200 mg qd on weekends long term
2. Fluconazole, exact same regimen if itraconazole not accessible
3. Oral Roflumilast, 250 ug qd x 2 wks, then 500 ug qd
4. Methotrexate at 10 mg qweek
5. Isotretinoin at 10 mg qd

Literature says oral terbinafine works just as well as fluconazole (Comparison the Efficacy of Fluconazo...

Depends if facial, scalp, or ear location and what has previously been tried.

I usually start with some form of ketoconazole (cream or shampoo), but some people respond better to other shampoos like ciclopirox, selenium sulfide, or pyrithione zinc or a rotation of a couple of the above.

I also will start with a foundation of topical steroids (solutions or oils for the scalp or creams/lotions for the face).

If those fail, I think pulsed fluconazole is certainly reasonable and effective. You hav...

When patients have recalcitrant disease and are fed up of cycling through topicals, I’ll do Isotretinoin at a goal dose of 150 mg/kg, similar to acne management. I’ve had good patient response with this.