In our routine clinical practice, seborrheic dermatitis (SD) is a common reason for seeking care. The prevalence of this condition is as high as 5% of the adult population. SD is a chronic and recurrent disease. It is common to see patients who have SD outbreaks with a certain degree of regularity, despite the availability of suitable topical treatment. As a general rule, oral treatment is reserved for more severe or resistant cases.

Gupta et al.1 conducted a systematic review of the oral treatments described for SD. The study included 21 publications that encompassed a diverse range of treatments, including 8 different oral medications. Most of the studies described the use of antifungal agents. Itraconazole was the most frequently used drug, because of the role of colonization by Malassezia species in the pathogenesis of SD.

Notable studies include those by Kose et al.2 and Baysal et al.,3 who initially administered itraconazole at a dose of 200mg/d for 7 days followed by pulses of itraconazole at a dose of 200mg on the first 2 days of each month, with follow-up at 3 and 12 months, respectively. In both studies, statistically significant clinical improvement was obtained. However, in a study by Shemer et al.4 the maintenance therapy was a single dose of 200mg itraconazole every 2 weeks, and significant improvement in the parameters of erythema, scaling, and pruritus was achieved. However, the quality of the scientific methodology of these studies is generally low and they do not include control groups or double-blind protocols.

It was not until the year 2015 that a randomized, double-blind clinical trial was carried out in 68 patients with moderate to severe SD. All patients in the study applied 1% hydrocortisone cream and 2% ketoconazole and were subsequently randomly assigned to a placebo group or a group that received oral itraconazole at a dose of 200mg/d for 7 days in the first phase, followed by pulse therapy at a dose of 200mg/d on the first 2 days of each month (400mg/mo) for the following 3 months in the second phase. A statistically significant decrease in the Seborrheic Dermatitis Area and Severity Index (SDASI) was found in the itraconazole group, as well as a lower recurrence rate. Clinical improvement was observed in 93.8%, 87.5%, and 93.1% of the patients treated with itraconazole at 2, 4, and 16 weeks, respectively, versus 82.1%, 64.3%, and 53.6% of patients in the placebo group. The treatment was well tolerated in all cases and no blood test anomalies were observed in any patients.5

In conclusion, the chronic and recurrent nature of SD can lead to the therapeutic failure of the topical treatments used to date and/or a low rate of adherence to treatment. A treatment that allows better long-term management of SD in these patients is therefore needed. Recent studies support the use of pulses of systemic itraconazole as a safe and effective treatment for controlling SD during outbreaks and also as maintenance therapy, with the aim of avoiding recurrences. Treatment with pulses of oral itraconazole could therefore be considered an interesting therapeutic tool, especially in patients who show poor adherence to topical treatment or have multiple recurrences despite following an appropriate topical treatment regimen.