A 62-year-old man comes to the community health center due to a "flaky and itchy" scalp. He is uncertain when the symptoms began and believes his brother has a similar problem. The patient has not attempted any specific treatments but washes his hair with a mild shampoo every other day and washes his face with cold water once daily. Medical history is notable for coronary artery disease, type 2 diabetes mellitus, benign prostatic hyperplasia, and diverticulosis. The patient is a recovering alcoholic and has lived in a group home for the last 3 months. Vital signs are normal. Physical examination shows oily skin with faint erythema and scaling of the scalp, eyebrows, and ears, as shown below. During the course of the visit, the patient repeatedly scratches his head and eyebrows, but the remainder of the skin examination is normal.
Which of the following is the best initial treatment for this patient?

Question

A 62-year-old man comes to the community health center due to a "flaky and itchy" scalp.  He is uncertain when the symptoms began and believes his brother has a similar problem.  The patient has not attempted any specific treatments but washes his hair with a mild shampoo every other day and washes his face with cold water once daily.  Medical history is notable for coronary artery disease, type 2 diabetes mellitus, benign prostatic hyperplasia, and diverticulosis.  The patient is a recovering alcoholic and has lived in a group home for the last 3 months.  Vital signs are normal.  Physical examination shows oily skin with faint erythema and scaling of the scalp, eyebrows, and ears, as shown below.  During the course of the visit, the patient repeatedly scratches his head and eyebrows, but the remainder of the skin examination is normal.  
Which of the following is the best initial treatment for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c129_4372_8f63_f1f9a09a4dfe_MD0005_00 This patient's erythematous, scaly rash has the typical appearance of seborrheic dermatitis (SD). SD predominantly affects areas with heavy concentrations of sebaceous glands, including the scalp (where it is referred to as "dandruff"), central face (eg, eyebrows, nasolabial folds), and ears. In addition, SD may occasionally be seen on the chest, upper back, axilla, and inguinal/pubic area. SD is most common in the first year of life and again in adulthood. The diagnosis of SD is primarily clinical, with typical findings characterized by pruritic, erythematous plaques with loose, greasy-looking scales. Malassezia species may play a role in the pathogenesis of SD, and topical antifungal agents (eg, ketoconazole, selenium sulfide) are effective in treating this condition. Other treatments that can be helpful include topical glucocorticoids, keratolytic agents (eg, salicylic acid), coal tar shampoo, and topical calcineurin inhibitors (eg, pimecrolimus, tacrolimus). (Choice A) Griseofulvin is used in tinea capitis, a dermatophyte infection most commonly seen in children, and tinea corporis, which causes annular plaques with peripheral scaling and central clearing. Griseofulvin is not effective against Malassezia species and can worsen SD. tinea corporis (Choice B) Oral antifungals (eg, itraconazole, ketoconazole) are occasionally used in SD, but they are not first-line treatments and are used primarily in severe, refractory cases. (Choice C) Permethrin is used to treat scabies, which presents with intensely pruritic papules and vesicles between the fingers as well as on the volar wrists, elbows, axillae, lower abdomen, or genitalia. Crusted scabies can cause large, scaly patches but is not pruritic and occurs most commonly in immunocompromised patients (eg, lymphoma, AIDS). scaly patches (Choice E) Topical nystatin is used primarily to treat intertrigo and other disorders caused by Candida species yeasts; it is not used in SD. Educational objective: Seborrheic dermatitis is characterized by erythematous plaques with loose, greasy-looking scales on the scalp ("dandruff"), central face, and ears. Treatment options include topical antifungal agents (eg, ketoconazole, selenium sulfide), keratolytic agents (eg, salicylic acid), coal tar, topical glucocorticoids, and topical calcineurin inhibitors (eg, pimecrolimus, tacrolimus). References: Diagnosis and treatment of seborrheic dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/25822272)

A 62-Year-Old Man Comes to the Community Health Center Due