Seborrheic Dermatitis

Seborrheic dermatitis (SD) is a chronic inflammatory dermatosis affecting sebaceous-rich areas and is among the five most common dermatologic diagnoses in Black individuals. In the general population, SD affects approximately 5 percent of individuals; however, prevalence is higher among African Americans, estimated at 6.5 percent. Skin lipids and colonization with Malassezia species plays a role in disease pathogenesis, with downstream inflammatory effects that can be more pronounced in darker skin tones. 

Clinical presentation of SD in skin of color differs from that observed in lighter Fitzpatrick types. In adults and adolescents with Fitzpatrick IV-VI, erythema is often poorly visualized and hypopigmentation may be a predominant feature in classical areas, such as scalp, face, and chest. In contrast, Fitzpatrick I-IV children more commonly present with visible erythema, desquamation, and hypopigmentation, often in association with underlying atopic dermatitis. SD may be asymptomatic or pruritic, and pigmentary changes frequently persist until underlying inflammation is treated. 

Scalp involvement is particularly prominent among Black women and may be influenced by less frequent scalp washing related to protective hairstyles and hair texture. It may also be influenced by the use of heavier hair oils and ointments. Certain oils, like coconut and olive oil, contribute to Malassezia proliferation and can obscure scale, delaying diagnosis.  

When evaluating patients with skin of color, clinicians should assess for hypo- and hyperpigmentation along the face, neck, and chest, as these changes should resolve with effective SD treatment. In patients with scalp involvement, examination for signs of alopecia is essential. Untreated inflammation can contribute to hair loss and should prompt more aggressive therapy. Management should be individualized to hair care practices. While antifungal shampoos containing selenium sulfide or zinc pyrithione are first-line therapy, frequent shampooing is impractical for patients who wash their hair once or twice monthly due to protective hairstyles and hair texture. Asking patients to describe their hair care routine is a critical first step when discussing treatment. For patients unable to wash frequently, antifungal ointments, oils, and foams applied to the scalp are more appropriate. Patients should be instructed to apply products to the scalp rather than the hair shaft to minimize dryness.