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Scenario

Claire Hawkins comes in and asks to speak to technician Vicky. 

“It’s not for me – it’s for Josh actually. He won’t come in himself,” says Claire, referring to her older son. Vicky recalls that he left college recently after completing a two-year vocational course.

“That’s a shame – he’s always been happy to chat to me,” replies Vicky. “What’s going on?”

“Oh, I’ve probably made it sound much worse than it really is, it’s nothing awful,” says Claire. “He’s just embarrassed, to be honest. Josh thought he was through all the puberty stuff because his acne seemed to have pretty much gone, but he’s got this kind of flaking skin thing going on now. I thought it was dandruff, but it’s on his face and even in his ears. Some of it looks quite red and sore, and he says it is itchy and painful in places. Any idea what it might be? And is there anything I can buy or do I need to persuade him to go to the doctor?”

Answer

It sounds as though Josh has seborrhoeic dermatitis, a condition associated with dandruff that can cause itching and scaling of the skin. The scalp is most likely to be affected, but other areas of the body that are commonly involved include the face, in and around the ears, the chest and upper back, and skin folds such the groin and armpits. Complications include issues with self-confidence and secondary infection – both of which seem to be afflicting Josh – and generalisation of the condition to the whole body. If the scalp if badly affected, there may be some degree of hair loss, though this is usually temporary.

Josh needs to visit his GP as it sounds as though he needs to be prescribed ketoconazole in two forms for a period of at least four weeks: a two per cent shampoo used at least twice a week for his scalp, and a two per cent cream applied once or twice a day to the affected areas of skin. He may also need a mildly potent corticosteroid to ease the inflammation and possibly antibiotics if there is a bacterial infection.

The bigger picture

Seborrhoeic dermatitis is considered to be the precursor of dandruff, and is thought to be associated with – though not caused by – the presence of yeasts of the Malassezia family. There is no link with hygiene, and the condition is believed to be relatively common, although it is difficult to put a figure on it, as many people do not seek medical help. Men are more likely to be affected than women, as are the very young (under three months of age, when it is usually called ‘cradle cap’), the middle-aged, people with Parkinson’s disease and those who are immune-compromised. Prevalence appears higher in the winter months.

The main symptom is red, greasy areas of skin that appear to be flaking. It may be itchy, and can affect the eyelids (blepharitis). Conditions it may be confused with include psoriasis, eczema, scabies, irritant dermatitis, candidiasis (thrush), and pityriasis versicolour. Treatment involves use of antifungal agents.

Extend your learning

• Could you distinguish dandruff from seborrhoeic dermatitis? Click here for pictures to help you.
• This scenario mentions the conditions cradle cap and dandruff. Are you confident that you could provide advice on how to deal with both of these, in terms of product recommendation and other measures? If you are unsure, refer to your pharmacy’s copy of Counter Intelligence Plus
• Do you sell any products that contain ketoconazole? If so, have a look at the labels to remind yourself of when it can be sold, and identify when a referral to a GP is necessary
• This scenario mentions ‘mildly potent corticosteroids’. Refer to the Topical Corticosteroids section of the BNF to find out which drugs fall under this heading, and which are moderate, potent and very potent
• Someone who presents with severe or persistent seborrheic dermatitis may end up being diagnosed with diabetes or even HIV. Can you think why might this be?