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 Roflu...

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...

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.