derm.seborrheic-dermatitis.core.v1PRODUCTION

derm.seborrheic-dermatitis.core.v1

Seborrheic dermatitis (incl. dandruff + infantile cradle cap)

dermatologychronicadultpediatricneonatal

Hard-required inputs

0 / 8

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a CHRONIC RELAPSING Malassezia-associated inflammatory dermatosis of sebaceous-rich skin managed by site/severity/age — induction THEN intermittent maintenance, NOT a one-off rash. Dandruff = the mild scalp variant; infantile cradle cap = a self-limited variant managed conservatively. Severe/explosive/extensive/erythrodermic or treatment-resistant SD is a flag for HIV / immunosuppression / Parkinson-neurologic disease; recalcitrant petechial infantile "SD" = the Langerhans-cell-histiocytosis / Leiner not-to-miss — both recognised here as escape routes.

Inputs

Actions

Advance rule

Set

Advance when

chronic relapsing SD framing set; dandruff + infantile variants + HIV/neuro + LCH/Leiner escape routes noted

Patient inputs (16)

inflammation_vs_pure_scaling*symptom • CONTEXT

Erythema/itch (inflammatory flare) vs pure flaking (dandruff) determines whether a short topical corticosteroid/CNI is added to the antifungal/keratolytic base (scalp-SD consensus PMID 38919137)

prior_topical_adequacy_and_relapse_pattern*history • CONTEXT

not present

True treatment failure (correct agent/site/duration/adherence) vs under-treatment, and the relapse interval, determine escalation vs a maintenance-prophylaxis plan (SD treatment landscape PMID 39953371)

hiv_immunosuppression_neurologic_risk*history • CONTEXT

not present

Severe/explosive/extensive/erythrodermic or treatment-resistant SD is a recognised marker of HIV, immunosuppression (transplant/chemo), and Parkinson/neurologic disease — screen accordingly (SD microbiology/immunology PMID 32125725)

lesion_distribution_and_scale_quality*symptom • ENTRY

Greasy/yellow scale on erythema confined to sebaceous-rich sites (scalp, nasolabial folds, brows, ears, central chest) is the diagnostic pivot vs psoriasis/eczema/rosacea/tinea (SD overview PMID 35967915)

age*demographic • ENTRY

Splits the engine into neonatal/infantile (cradle cap — conservative, self-limited) vs adolescent/adult SD; gates agent potency and oral-antifungal eligibility (infantile SD review PMID 39526559)

erythroderma_or_extensive_severe_extent*symptom • RED_FLAGS

>90% BSA confluent erythema / extensive severe SD carries thermoregulatory-fluid risk and is a strong HIV/immunosuppression flag mandating urgent screening + systemic therapy (SD microbiology/immunology PMID 32125725)

infantile_recalcitrant_petechial_failure_to_thrive*symptom • RED_FLAGS

Infantile "SD" that is recalcitrant, petechial/purpuric, erosive, or with failure-to-thrive/diarrhoea/lymphadenopathy → exclude Langerhans-cell histiocytosis / Leiner's disease (not-to-miss — biopsy + immune workup) (Leiner's disease review PMID 33166012)

body_site_and_extent*symptom • RISK_STRATIFICATION

Site (scalp vs face vs body vs intertriginous) and BSA/extent drive the site-stratified ladder branch and the mild/moderate/severe tier (scalp-SD consensus PMID 38919137)

sebopsoriasis_overlap_featuressymptom • BRANCHING_WORKUP

Sharper-bordered thicker silvery-scaled plaques, scalp plaques extending beyond the hairline, nail pitting, or extensor involvement argue sebopsoriasis/psoriasis → route derm.psoriasis.core.v1 (scalp-SD consensus PMID 38919137)

koh_indicated_featuressymptom • BRANCHING_WORKUP

Scaly scalp/face plaque with alopecia, broken hairs, or an annular advancing border → KOH/fungal exam to exclude tinea capitis/faciei before attributing to SD (route derm.tinea-dermatophytosis.core.v1) (SD overview PMID 35967915)

hiv_testlab • BRANCHING_WORKUP

Explosive/extensive/erythrodermic/treatment-resistant SD in an adult → offer HIV testing (SD can be the presenting sign of advanced HIV) (SD microbiology/immunology PMID 32125725)

cbc_with_differentiallab • INITIAL_WORKUP

Adjunct for the underlying-immunosuppression workup in severe/explosive SD and the recalcitrant-infant LCH/Leiner evaluation (SD microbiology/immunology PMID 32125725; Leiner's review PMID 33166012)

pregnancy_lactationhistory • TREATMENT

not present

Oral azole antifungals are avoided in pregnancy; topical ketoconazole/calcineurin-inhibitor use is cautious — gates the severe-SD systemic branch (SD treatment landscape PMID 39953371)

facial_corticosteroid_exposurehistory • TREATMENT

not present

Prolonged facial potent-corticosteroid use causes atrophy/telangiectasia/steroid-rosacea/perioral dermatitis — drives the preference for CNI/antifungal/roflumilast at facial sites (scalp-SD consensus PMID 38919137; SD treatment landscape PMID 39953371)

lftlab • TREATMENT

Baseline + on-treatment hepatic monitoring if an oral azole antifungal (itraconazole/fluconazole) is used for severe/widespread SD (SD treatment landscape PMID 39953371)

concomitant_medications_cyp3a4history • TREATMENT

not present

Itraconazole/fluconazole are CYP3A4 inhibitors with major DDIs (statins, calcineurin inhibitors, DOACs, etc.) — medication reconciliation gates oral-antifungal selection (SD treatment landscape PMID 39953371)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement

informationallife_threateninginfantile_recalcitrant_petechial_failure_to_thrive_lch_leiner
Infantile "SD-like" eruption that is recalcitrant, petechial/purpuric, erosive, or with failure-to-thrive / diarrhoea / lymphadenopathy
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereerythrodermic_or_extensive_severe_sd_hiv_flag
>90% BSA confluent erythema / extensive severe SD — thermoregulatory-fluid risk AND a strong marker of advanced HIV or immunosuppression
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereexplosive_sudden_onset_severe_sd_in_at_risk_adult
Abrupt explosive severe or treatment-resistant SD in an adult (esp. with HIV-risk factors or new immunosuppression)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatetreatment_resistant_sd_reassess_dx_and_underlying_disease
SD not responding to an adequate site-appropriate topical/oral trial after adherence/vehicle optimisation
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatesevere_inflammatory_scalp_sd_with_hair_shedding_or_secondary_infection
Intensely inflammatory scalp SD with telogen hair shedding or secondary bacterial impetiginisation
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmildprolonged_facial_steroid_overuse_iatrogenic_harm
Ongoing/prolonged potent facial corticosteroid use for SD with emerging atrophy / telangiectasia / steroid-rosacea / perioral dermatitis / rebound
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENToptionalDrives dose adjustment

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Recommended regimen

Seborrheic dermatitis — site/severity/age-stratified ladder + relapse-prevention maintenance (scalp-SD consensus 2024 + SD reviews 2022/2025)

axis: sd_site_severity_age_stratified_ladderstep 1 - Step 1 — Scalp / dandruff (antifungal-keratolytic medicated shampoo ± short steroid solution for flare)

Selected step "Step 1 — Scalp / dandruff (antifungal-keratolytic medicated shampoo ± short steroid solution for flare)" — Scalp-predominant SD or dandruff/pityriasis capitis (the mild non-inflammatory scalp variant) in adolescents/adults

ketoconazole
first line
topical_azole_antifungal
2% shampoo • topical • 2×/week induction (~4 wk) then weekly–fortnightly maintenance (max: per labeling)
triggers: scalp_sd, dandruff
Scalp-SD consensus (PMID 38919137) + SD overview (PMID 35967915) — anti-Malassezia azole; first-line scalp SD/dandruff; ketoconazole 2% significantly reduces SD severity vs vehicle (Rousel RCT PMID 37762625).
rxcui 6135
ciclopirox
first line
hydroxypyridone_antifungal
1% (or 1.5%) shampoo • topical • 2–3×/week induction then weekly–fortnightly maintenance (max: per labeling)
triggers: scalp_sd, dandruff, azole_alternative
Lebwohl RCT (PMID 15271196) — ciclopirox 1% shampoo "effective treatment" 26.0% vs vehicle 12.9% (OR 2.38, 95% CI 1.49–3.80); broad-spectrum antifungal + anti-inflammatory.
rxcui 21090
selenium sulfide
first line
antiseborrheic_antifungal
1%–2.5% shampoo • topical • 2×/week induction then weekly maintenance (max: per labeling)
triggers: scalp_sd, dandruff, cost_access_barrier
Scalp-SD consensus (PMID 38919137) — antifungal/antiproliferative medicated shampoo; effective low-cost first-line scalp option (can discolour hair / scalp irritation).
rxcui 36345
zinc pyrithione
first line
antiseborrheic_antifungal
1%–2% shampoo • topical • 2–3×/week then maintenance (max: per labeling)
triggers: dandruff, mild_scalp_sd, otc_preferred
Scalp-SD consensus (PMID 38919137) — anti-Malassezia OTC medicated shampoo; well tolerated; mainstay of dandruff and mild scalp SD.
rxcui 39952
coal tar
second line
keratoplastic_antiseborrheic
0.5%–5% shampoo • topical • 1–3×/week (max: per preparation)
triggers: scalp_sd_with_thick_scale, antifungal_intolerant, sebopsoriasis_overlap
Scalp-SD consensus (PMID 38919137) — keratoplastic/antiproliferative adjunct, useful with thick scale or sebopsoriasis overlap; cosmetic acceptability (odour/staining) limits use.
rxcui 2635
salicylic acid
add on
keratolytic
2%–6% shampoo/solution/oil • topical • as descaling adjunct then taper (max: per preparation)
triggers: thick_adherent_scalp_scale, pityriasis_amiantacea_pattern
SD overview (PMID 35967915) — keratolytic to debulk thick adherent scale (incl. pityriasis-amiantacea pattern) so antifungal/anti-inflammatory agents can penetrate; descaling adjunct, not monotherapy.
rxcui 9525
clobetasol propionate
rescue
high_potency_topical_corticosteroid
0.05% scalp solution/foam/shampoo • topical • short burst (≤2–4 wk) for an inflammatory flare then stop (max: limited duration; scalp only; not for face/folds)
triggers: severe_inflammatory_scalp_flare, intensely_itchy_erythematous_scalp
Scalp-SD consensus (PMID 38919137) — short corticosteroid solution/foam burst layered on the antifungal base rapidly controls an inflammatory scalp flare; time-limited (folliculitis/atrophy/rebound) — antifungal shampoo carries maintenance.
rxcui 21245

outpatient playbook — drug actions (4)

1. ketoconazole 2% shampoo (scalp/dandruff) — antifungal/keratolytic base
rxcui 6135
2% shampoo • topical • 2×/wk induction then weekly–fortnightly maintenance
trigger: Scalp-predominant SD or dandruff (scalp-SD consensus PMID 38919137)
Anti-Malassezia first-line; maintenance shampoo carries relapse control
2. ketoconazole 2% cream + pimecrolimus/roflumilast foam (face/body, steroid-sparing)
rxcui 6135
2% cream / 1% / 0.3% • topical • antifungal BID + CNI/roflumilast for flare then maintenance
trigger: Facial/body SD (SD overview PMID 35967915; STRATUM PMID 38253129)
Topical antifungal + steroid-sparing anti-inflammatory; roflumilast foam FDA-approved non-steroidal
3. oral itraconazole pulse + parallel HIV/immunosuppression/neuro workup
rxcui 28031
200 mg/day induction then monthly pulse • PO • induction then monthly pulse
trigger: Severe/extensive/erythrodermic/recalcitrant SD (SD treatment landscape PMID 39953371; SD microbiology/immunology PMID 32125725)
Oral azole reserved for severe disease; severe SD is an HIV/immunosuppression flag — investigate concurrently; LFT + DDI monitoring
4. emollient/oil + soft brushing + gentle baby shampoo (infant cradle cap)
conservative • topical • regular
trigger: Infantile SD without red-flag features (infantile SD review PMID 39526559)
Self-limited — reassure; avoid potent steroids/oral antifungals; safety-net for petechial/failure-to-thrive change

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Greasy yellow-white scale on erythematous skin in a seborrheic distribution (scalp, brows, glabella, nasolabial folds, ears, central chest) (SD overview Dall'Oglio PMID 35967915); Diffuse fine scalp flaking ± itch without overt inflammation — dandruff / pityriasis capitis, the mild scalp variant of SD (scalp-SD consensus Vano-Galvan PMID 38919137); Infant with greasy yellow adherent scalp scale ± flexural involvement in the first months of life — cradle cap (infantile SD) (infantile SD microbiome review PMID 39526559).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Seborrheic dermatitis (incl. dandruff + infantile cradle cap)** (derm.seborrheic-dermatitis.core.v1).
Phenotype framing: Terminal differential with named pivots: SD (greasy yellow scale + seborrheic distribution + Malassezia-responsive pivot) vs scalp/facial psoriasis & sebopsoriasis (sharper border + thicker silvery scale + nail pits + Auspitz + scalp beyond hairline pivot — route derm.psoriasis.core.v1) vs atopic dermatitis (ill-defined itchy flexural + atopy pivot — route derm.atopic-dermatitis.core.v1) vs rosacea (centrofacial flushing/papulopustules, NO scale pivot — route derm.rosacea.core.v1) vs tinea capitis/faciei (KOH+ annular advancing border + alopecia pivot — route derm.tinea-dermatophytosis.core.v1) vs contact dermatitis (geometric margin + exposure pivot — route derm.contact-dermatitis.core.v1) vs DLE/SCLE (photodistributed, scarring, follicular plugging + serology/biopsy pivot) vs Langerhans-cell histiocytosis (infantile recalcitrant petechial/erosive + biopsy pivot — not-to-miss) vs pityriasis amiantacea (asbestos-like hair-binding scale — reaction-pattern pivot) vs secondary syphilis (palmoplantar + mucous patches + RPR/TPPA pivot).
Scope: Frame as a CHRONIC RELAPSING Malassezia-associated inflammatory dermatosis of sebaceous-rich skin managed by site/severity/age — induction THEN intermittent maintenance, NOT a one-off rash. Dandruff = the mild scalp variant; infantile cradle cap = a self-limited variant managed conservatively. Severe/explosive/extensive/erythrodermic or treatment-resistant SD is a flag for HIV / immunosuppression / Parkinson-neurologic disease; recalcitrant petechial infantile "SD" = the Langerhans-cell-histiocytosis / Leiner not-to-miss — both recognised here as escape routes.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Seborrheic dermatitis — site/severity/age-stratified ladder + relapse-prevention maintenance (scalp-SD consensus 2024 + SD reviews 2022/2025)** — step "Step 1 — Scalp / dandruff (antifungal-keratolytic medicated shampoo ± short steroid solution for flare)".
1. ketoconazole 2% shampoo topical 2×/week induction (~4 wk) then weekly–fortnightly maintenance (topical_azole_antifungal, first line) — Scalp-SD consensus (PMID 38919137) + SD overview (PMID 35967915) — anti-Malassezia azole; first-line scalp SD/dandruff; ketoconazole 2% significantly reduces SD severity vs vehicle (Rousel RCT PMID 37762625).
2. ciclopirox 1% (or 1.5%) shampoo topical 2–3×/week induction then weekly–fortnightly maintenance (hydroxypyridone_antifungal, first line) — Lebwohl RCT (PMID 15271196) — ciclopirox 1% shampoo "effective treatment" 26.0% vs vehicle 12.9% (OR 2.38, 95% CI 1.49–3.80); broad-spectrum antifungal + anti-inflammatory.
3. selenium sulfide 1%–2.5% shampoo topical 2×/week induction then weekly maintenance (antiseborrheic_antifungal, first line) — Scalp-SD consensus (PMID 38919137) — antifungal/antiproliferative medicated shampoo; effective low-cost first-line scalp option (can discolour hair / scalp irritation).
4. zinc pyrithione 1%–2% shampoo topical 2–3×/week then maintenance (antiseborrheic_antifungal, first line) — Scalp-SD consensus (PMID 38919137) — anti-Malassezia OTC medicated shampoo; well tolerated; mainstay of dandruff and mild scalp SD.
5. coal tar 0.5%–5% shampoo topical 1–3×/week (keratoplastic_antiseborrheic, second line) — Scalp-SD consensus (PMID 38919137) — keratoplastic/antiproliferative adjunct, useful with thick scale or sebopsoriasis overlap; cosmetic acceptability (odour/staining) limits use.
6. salicylic acid 2%–6% shampoo/solution/oil topical as descaling adjunct then taper (keratolytic, add on) — SD overview (PMID 35967915) — keratolytic to debulk thick adherent scale (incl. pityriasis-amiantacea pattern) so antifungal/anti-inflammatory agents can penetrate; descaling adjunct, not monotherapy.
7. clobetasol propionate 0.05% scalp solution/foam/shampoo topical short burst (≤2–4 wk) for an inflammatory flare then stop (high_potency_topical_corticosteroid, rescue) — Scalp-SD consensus (PMID 38919137) — short corticosteroid solution/foam burst layered on the antifungal base rapidly controls an inflammatory scalp flare; time-limited (folliculitis/atrophy/rebound) — antifungal shampoo carries maintenance.

Setting playbook (outpatient) — Confirm clinical SD (exclude sebopsoriasis/eczema/rosacea/tinea + the LCH/Leiner and HIV/immunosuppression not-to-miss), start the site/severity/age-stratified ladder, and lock in relapse-prevention maintenance counselling — gating agent choice on facial-steroid-avoidance, pregnancy, infancy, and oral-azole DDIs (scalp-SD consensus PMID 38919137; SD reviews PMID 35967915 + 39953371)
8. ketoconazole 2% shampoo (scalp/dandruff) — antifungal/keratolytic base 2% shampoo topical 2×/wk induction then weekly–fortnightly maintenance — Scalp-predominant SD or dandruff (scalp-SD consensus PMID 38919137) (Anti-Malassezia first-line; maintenance shampoo carries relapse control)
9. ketoconazole 2% cream + pimecrolimus/roflumilast foam (face/body, steroid-sparing) 2% cream / 1% / 0.3% topical antifungal BID + CNI/roflumilast for flare then maintenance — Facial/body SD (SD overview PMID 35967915; STRATUM PMID 38253129) (Topical antifungal + steroid-sparing anti-inflammatory; roflumilast foam FDA-approved non-steroidal)
10. oral itraconazole pulse + parallel HIV/immunosuppression/neuro workup 200 mg/day induction then monthly pulse PO induction then monthly pulse — Severe/extensive/erythrodermic/recalcitrant SD (SD treatment landscape PMID 39953371; SD microbiology/immunology PMID 32125725) (Oral azole reserved for severe disease; severe SD is an HIV/immunosuppression flag — investigate concurrently; LFT + DDI monitoring)
11. emollient/oil + soft brushing + gentle baby shampoo (infant cradle cap) conservative topical regular — Infantile SD without red-flag features (infantile SD review PMID 39526559) (Self-limited — reassure; avoid potent steroids/oral antifungals; safety-net for petechial/failure-to-thrive change)

Non-pharmacologic actions:
- Written induction + intermittent maintenance-prophylaxis plan; explain SD is controllable but relapsing, not curable (SD treatment landscape PMID 39953371)
- Facial steroid-sparing counselling — avoid prolonged potent facial corticosteroid (atrophy/steroid-rosacea/rebound) (scalp-SD consensus PMID 38919137)
- Trigger counselling — stress, cold/dry season, infrequent washing; descale thick scalp scale with salicylic acid before antifungal (SD overview PMID 35967915)
- Infant: reassurance + explicit petechial/erosive/failure-to-thrive return precautions (Leiner's review PMID 33166012)

AVOID / contraindication checks:
- Against prolonged facial potent corticosteroid atrophy steroid rosacea perioral dermatitis rebound (scalp SD consensus PMID 38919137; SD treatment landscape PMID 39953371 — prefer CNI / topical antifungal / roflumilast for facial maintenance)
- Oral azole antifungal hepatotoxicity requires baseline and on treatment LFT (SD treatment landscape PMID 39953371)
- Itraconazole fluconazole cyp3a4 inhibition major DDI reconcile statins CNI DOAC etc (SD treatment landscape PMID 39953371)
- Infants avoid potent topical corticosteroids and oral antifungals (infantile SD review PMID 39526559 — conservative emollient/gentle shampoo first; self limited)
- Pregnancy lactation topical first avoid oral azoles cautious topical ketoconazole and CNI (SD treatment landscape PMID 39953371)
- Severe explosive extensive or erythrodermic SD mandates HIV immunosuppression neurologic screen not just escalated topicals (SD microbiology/immunology PMID 32125725)
- Recalcitrant petechial or failure to thrive infantile SD is not SD exclude Langerhans cell histiocytosis Leiner (Leiner's disease review PMID 33166012)

Monitoring

Regimen monitoring:
- response reassessed at 2-4 weeks; non-response → re-examine diagnosis (KOH/biopsy) + re-screen underlying HIV/immunosuppression/neuro (SD overview PMID 35967915; SD microbiology/immunology PMID 32125725)
- oral azole antifungal: baseline + on-treatment LFT (panel.lft) + CYP3A4 DDI surveillance (SD treatment landscape PMID 39953371)
- fluconazole renal dose-adjust via calc.ckd epi 2021 when used (SD treatment landscape PMID 39953371)
- facial corticosteroid: atrophy/telangiectasia/perioral-dermatitis/rebound vigilance + early step-down to steroid-sparing maintenance (scalp-SD consensus PMID 38919137)
- relapse is expected: reinforce intermittent maintenance-prophylaxis adherence at every visit (SD treatment landscape PMID 39953371)
- infant: reassure (self-limited) + safety-net return precautions for petechial/erosive/failure-to-thrive change (Leiner's review PMID 33166012)

Setting (outpatient) monitoring:
- Reassess response at 2–4 wk; non-response → KOH/biopsy + re-screen HIV/immunosuppression/neuro (SD overview PMID 35967915)
- Oral azole → baseline + on-treatment LFT + CYP3A4 DDI surveillance (SD treatment landscape PMID 39953371)
- Reinforce maintenance-prophylaxis adherence at every visit (relapse expected) (SD treatment landscape PMID 39953371)

Follow-up plan: Chronic relapsing-disease maintenance: intermittent prophylactic antifungal shampoo/topical to recurrence-prone sites (the core of relapse control — counsel explicitly), facial steroid-sparing maintenance (CNI / antifungal / roflumilast), trigger counselling (stress, cold/dry season, infrequent washing), and education that SD is controllable but not curable. For the infant: reassure (self-limited, typically resolves by ~8–12 months) with return precautions for petechial/erosive/failure-to-thrive change. Re-evaluate for HIV/neurologic disease at follow-up if the course remains atypically severe or treatment-resistant.
- Close-out criterion: maintenance-prophylaxis + trigger counselling + relapse education documented; infant reassured with return precautions; underlying-disease re-screen if course atypical

Monitoring phase: Disease: reassess response at 2–4 weeks (most topical SD responds in 2–4 wk); if no response, re-examine the diagnosis (KOH, biopsy) and re-screen for underlying HIV/immunosuppression/neurologic disease. Drug safety: oral azole antifungal → baseline + on-treatment LFT (panel.lft) and CYP3A4 DDI surveillance; facial corticosteroid → atrophy/telangiectasia/perioral-dermatitis/rebound vigilance and early step-down to a steroid-sparing agent. Counsel that relapse is expected and reinforce maintenance adherence.

Disposition

Current setting: outpatient — Confirm clinical SD (exclude sebopsoriasis/eczema/rosacea/tinea + the LCH/Leiner and HIV/immunosuppression not-to-miss), start the site/severity/age-stratified ladder, and lock in relapse-prevention maintenance counselling — gating agent choice on facial-steroid-avoidance, pregnancy, infancy, and oral-azole DDIs (scalp-SD consensus PMID 38919137; SD reviews PMID 35967915 + 39953371)

Disposition criteria:
- Routine SD → primary-care/derm continuity with induction + maintenance plan (no admission)
- Step up the ladder if an adequate topical/shampoo trial fails after adherence/vehicle optimisation
- Refer OUT for underlying-disease (HIV/immunosuppression/neuro) or LCH/Leiner workup in red-flag presentations

Escalation triggers (move to higher acuity):
- Erythrodermic / extensive severe SD → urgent HIV/immunosuppression screen + dermatology; admit only if thermoregulatory/fluid compromise
- Explosive sudden-onset severe SD in an at-risk adult → HIV testing pathway
- Recalcitrant petechial / erosive / failure-to-thrive infant → urgent paediatric dermatology / heme-onc for Langerhans-cell histiocytosis / Leiner workup

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Infantile "SD-like" eruption that is recalcitrant, petechial/purpuric, erosive, or with failure-to-thrive / diarrhoea / lymphadenopathy
- [SEVERE] >90% BSA confluent erythema / extensive severe SD — thermoregulatory-fluid risk AND a strong marker of advanced HIV or immunosuppression
- [SEVERE] Abrupt explosive severe or treatment-resistant SD in an adult (esp. with HIV-risk factors or new immunosuppression)

Citations

- No SD-specific society guideline exists — authority chain: scalp-SD international expert consensus + treatment algorithm (Vano-Galvan et al, Eur J Dermatol 2024; PMID 38919137) + SD diagnosis & management overview, all sites + infantile (Dall'Oglio et al, Clin Cosmet Investig Dermatol 2022; PMID 35967915) + child & adult SD treatment-landscape review positioning roflumilast foam as potential first-line (Vidal/Green et al, Dermatol Ther 2025; PMID 39953371) + current understanding of SD treatment options (Turchin et al, J Cutan Med Surg 2025; PMID 40965088); anchored by the STRATUM roflumilast-foam phase-3 RCT (Blauvelt et al, JAAD 2024; PMID 38253129), ketoconazole + ciclopirox + pimecrolimus SD RCTs, and the SD–HIV/Parkinson/immunology evidence (Adalsteinsson et al, Exp Dermatol 2020; PMID 32125725) [PMID:38919137](https://pubmed.ncbi.nlm.nih.gov/38919137/)
- Cited evidence (PMID 35967915) [PMID:35967915](https://pubmed.ncbi.nlm.nih.gov/35967915/)
- Cited evidence (PMID 39953371) [PMID:39953371](https://pubmed.ncbi.nlm.nih.gov/39953371/)
- Cited evidence (PMID 40965088) [PMID:40965088](https://pubmed.ncbi.nlm.nih.gov/40965088/)
- Cited evidence (PMID 38253129) [PMID:38253129](https://pubmed.ncbi.nlm.nih.gov/38253129/)

Last reconciled with current guidelines: 2026-05-22.

References

No SD-specific society guideline exists — authority chain: scalp-SD international expert consensus + treatment algorithm (Vano-Galvan et al, Eur J Dermatol 2024; PMID 38919137) + SD diagnosis & management overview, all sites + infantile (Dall'Oglio et al, Clin Cosmet Investig Dermatol 2022; PMID 35967915) + child & adult SD treatment-landscape review positioning roflumilast foam as potential first-line (Vidal/Green et al, Dermatol Ther 2025; PMID 39953371) + current understanding of SD treatment options (Turchin et al, J Cutan Med Surg 2025; PMID 40965088); anchored by the STRATUM roflumilast-foam phase-3 RCT (Blauvelt et al, JAAD 2024; PMID 38253129), ketoconazole + ciclopirox + pimecrolimus SD RCTs, and the SD–HIV/Parkinson/immunology evidence (Adalsteinsson et al, Exp Dermatol 2020; PMID 32125725) — PMID:38919137
Cited evidence (PMID 35967915) — PMID:35967915
Cited evidence (PMID 39953371) — PMID:39953371
Cited evidence (PMID 40965088) — PMID:40965088
Cited evidence (PMID 38253129) — PMID:38253129