"It's the Pits"

The several-week duration of this 14-year-old boy’s rash is worrisome to him and his family, despite a lack of other symptoms. Located on his right axilla, the rash was previously diagnosed as “yeast infection” but was unaffected by topical anti-yeast medications (nystatin and clotrimazole creams) and oral fluconazole.

A serious family crisis preceded the appearance of the rash: The parents lost custody of their children, who were then placed under the care of grandparents in another state. The boy lost his family and friends and had to start again in a new school.

EXAMINATION
Additional rashes are present on his face, in and behind his ears, and on focal areas of his genitals. They are all orangish red with faintly scaly surfaces. The scale on his face, ears, and genitals is coarser than that of his axilla, but it is the same salmon-pink. Focal areas of his brows and scalp are also involved.

What is the diagnosis?

 

DISCUSSION
Seborrhea, or seborrheic dermatitis, is most commonly seen on the scalp in the form of dandruff, but it can also flare in other locations. Seborrhea is an adverse inflammatory response to the consumption of sebum by commensal yeast organisms (eg, Pityrosporum) on oil-rich skin. Stress is believed to trigger flares (as exemplified in this case), presumably because it increases the production and outflow of sebum.

Non-dermatology providers often incorrectly diagnose axillary rashes as yeast infections, or seborrhea on the face as fungal infection, simply for lack of a complete differential. The truth is, yeast infections of the skin are unusual. The differential should include psoriasis or eczema, as well as sebopsoriasis (an overlap condition with signs of both seborrhea and psoriasis).

The “trick” to diagnosing seborrhea is to recognize that it is incredibly common (affecting around 30% of the Caucasian population), is often inherited, and can affect multiple sites. When it is seen in one area, corroboration can be sought by locating typical changes elsewhere.

Although there is no cure, control is obtained through use of topical anti-yeast creams (eg, ketoconazole) combined with a mild topical steroid (eg, 2.5% hydrocortisone). Using ketoconazole 2% shampoo for the scalp and other affected areas can be helpful as well. Use of nystatin, however, has long been replaced by more effective alternatives.

With a bit of luck, the patient’s stress will diminish over time, which should be a big help in resolving this problem.

TAKE-HOME LEARNING POINTS

• Seborrhea, or seborrheic dermatitis, is extremely common among those of northern European descent and can affect not only the scalp, but also the face, ears, chest, axillae, and genitals.
• The rash is usually orangish pink and slightly scaly, unless it’s in the axillae, where moisture and friction preclude the formation of significant scale.
• Seborrhea is often misdiagnosed as yeast infection, but the latter is quite unusual on the skin.
• The differential should include psoriasis, eczema, and sebopsoriasis (an overlap condition with signs of both seborrhea and psoriasis).

The several-week duration of this 14-year-old boy’s rash is worrisome to him and his family, despite a lack of other symptoms. Located on his right axilla, the rash was previously diagnosed as “yeast infection” but was unaffected by topical anti-yeast medications (nystatin and clotrimazole creams) and oral fluconazole.

A serious family crisis preceded the appearance of the rash: The parents lost custody of their children, who were then placed under the care of grandparents in another state. The boy lost his family and friends and had to start again in a new school.

EXAMINATION
Additional rashes are present on his face, in and behind his ears, and on focal areas of his genitals. They are all orangish red with faintly scaly surfaces. The scale on his face, ears, and genitals is coarser than that of his axilla, but it is the same salmon-pink. Focal areas of his brows and scalp are also involved.

What is the diagnosis?

 

DISCUSSION
Seborrhea, or seborrheic dermatitis, is most commonly seen on the scalp in the form of dandruff, but it can also flare in other locations. Seborrhea is an adverse inflammatory response to the consumption of sebum by commensal yeast organisms (eg, Pityrosporum) on oil-rich skin. Stress is believed to trigger flares (as exemplified in this case), presumably because it increases the production and outflow of sebum.

Non-dermatology providers often incorrectly diagnose axillary rashes as yeast infections, or seborrhea on the face as fungal infection, simply for lack of a complete differential. The truth is, yeast infections of the skin are unusual. The differential should include psoriasis or eczema, as well as sebopsoriasis (an overlap condition with signs of both seborrhea and psoriasis).

The “trick” to diagnosing seborrhea is to recognize that it is incredibly common (affecting around 30% of the Caucasian population), is often inherited, and can affect multiple sites. When it is seen in one area, corroboration can be sought by locating typical changes elsewhere.

Although there is no cure, control is obtained through use of topical anti-yeast creams (eg, ketoconazole) combined with a mild topical steroid (eg, 2.5% hydrocortisone). Using ketoconazole 2% shampoo for the scalp and other affected areas can be helpful as well. Use of nystatin, however, has long been replaced by more effective alternatives.

With a bit of luck, the patient’s stress will diminish over time, which should be a big help in resolving this problem.

TAKE-HOME LEARNING POINTS

• Seborrhea, or seborrheic dermatitis, is extremely common among those of northern European descent and can affect not only the scalp, but also the face, ears, chest, axillae, and genitals.
• The rash is usually orangish pink and slightly scaly, unless it’s in the axillae, where moisture and friction preclude the formation of significant scale.
• Seborrhea is often misdiagnosed as yeast infection, but the latter is quite unusual on the skin.
• The differential should include psoriasis, eczema, and sebopsoriasis (an overlap condition with signs of both seborrhea and psoriasis).

The several-week duration of this 14-year-old boy’s rash is worrisome to him and his family, despite a lack of other symptoms. Located on his right axilla, the rash was previously diagnosed as “yeast infection” but was unaffected by topical anti-yeast medications (nystatin and clotrimazole creams) and oral fluconazole.

A serious family crisis preceded the appearance of the rash: The parents lost custody of their children, who were then placed under the care of grandparents in another state. The boy lost his family and friends and had to start again in a new school.

EXAMINATION
Additional rashes are present on his face, in and behind his ears, and on focal areas of his genitals. They are all orangish red with faintly scaly surfaces. The scale on his face, ears, and genitals is coarser than that of his axilla, but it is the same salmon-pink. Focal areas of his brows and scalp are also involved.

What is the diagnosis?

 

DISCUSSION
Seborrhea, or seborrheic dermatitis, is most commonly seen on the scalp in the form of dandruff, but it can also flare in other locations. Seborrhea is an adverse inflammatory response to the consumption of sebum by commensal yeast organisms (eg, Pityrosporum) on oil-rich skin. Stress is believed to trigger flares (as exemplified in this case), presumably because it increases the production and outflow of sebum.

Non-dermatology providers often incorrectly diagnose axillary rashes as yeast infections, or seborrhea on the face as fungal infection, simply for lack of a complete differential. The truth is, yeast infections of the skin are unusual. The differential should include psoriasis or eczema, as well as sebopsoriasis (an overlap condition with signs of both seborrhea and psoriasis).

The “trick” to diagnosing seborrhea is to recognize that it is incredibly common (affecting around 30% of the Caucasian population), is often inherited, and can affect multiple sites. When it is seen in one area, corroboration can be sought by locating typical changes elsewhere.

Although there is no cure, control is obtained through use of topical anti-yeast creams (eg, ketoconazole) combined with a mild topical steroid (eg, 2.5% hydrocortisone). Using ketoconazole 2% shampoo for the scalp and other affected areas can be helpful as well. Use of nystatin, however, has long been replaced by more effective alternatives.

With a bit of luck, the patient’s stress will diminish over time, which should be a big help in resolving this problem.

TAKE-HOME LEARNING POINTS

• Seborrhea, or seborrheic dermatitis, is extremely common among those of northern European descent and can affect not only the scalp, but also the face, ears, chest, axillae, and genitals.
• The rash is usually orangish pink and slightly scaly, unless it’s in the axillae, where moisture and friction preclude the formation of significant scale.
• Seborrhea is often misdiagnosed as yeast infection, but the latter is quite unusual on the skin.
• The differential should include psoriasis, eczema, and sebopsoriasis (an overlap condition with signs of both seborrhea and psoriasis).