Kualitas Hidup Pasien Dermatitis Seboroik

1/3/2021 Clinical Characteristics and Quality of Life of Seborrheic Dermatitis Patients in a Tropical Country
Indian J Dermatol. 2015 Sep-Oct; 60(5): 519. PMCID: PMC4601435

doi: 10.4103/0019-5154.164410: 10.4103/0019-5154.164410 PMID: 26538714
Clinical Characteristics and Quality of Life of Seborrheic Dermatitis

Patients in a Tropical Country
Manapajon Araya, Kanokvalai Kulthanan, and Sukhum Jiamton
From the Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Address for correspondence: Dr. Kanokvalai Kulthanan, Department of Dermatology, Faculty of Medicine Siriraj,
Hospital Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand. E-mail:
kanokvalai.kul@mahidol.ac.th
Received 2014 Dec; Accepted 2015 Apr.
Copyright : © Indian Journal of Dermatology
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-
ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as
the author is credited and the new creations are licensed under the identical terms.
Abstract
Background:
Seborrheic dermatitis is a common chronic inflammatory skin condition that can have a negative impact on
a patient's quality of life. Few studies have been conducted to assess the clinical characteristics of the
disease and quality of life of the patients, especially in tropical countries.
Aims and Objectives:

The aim of this study was to demonstrate the clinical characteristics and quality of life of patients with
seborrheic dermatitis in Thailand.
Materials and Methods:

A cross-sectional study was performed at a university-based hospital and tertiary referral center in
Bangkok, Thailand. The validated Thai version of the dermatology life quality index (DLQI) was used to
evaluate patients’ quality of life.
Results:
A total of 166 participants were included. One hundred and forty-seven patients (88.6%) experienced
multiple episodes of the eruption. The mean of outbreaks was 7.8 times per years, ranging from once every
4 years to weekly eruption. The most common factor reported to aggravate seborrheic dermatitis was
seasonality (34.9%), especially hot climate. The mean (SD) of the total DLQI score was 8.1 (6.0) with a
range of 0 to 27. There was no statistically significant difference between the two DLQI categories
regarding duration of disease, extent of involvement, symptoms or course of the disease.
Conclusion:
Although mild and asymptomatic, seborrheic dermatitis can have a great impact on the quality of life.
Youth, female gender, and scalp lesions were significantly associated with higher DLQI scores.
Keywords: Characteristics, DLQI, quality of life, seborrheic dermatitis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4601435/?report=printable 1/14
What was known?
Seborrheic dermatitis is a common chronic inflammatory skin that can have a negative impact on a
patient's quality of life. Harsh environment (low temperature and humidity in winter) on skin barrier is
responsible for high frequency of seborrheic dermatitis in temperate countries.
Introduction
Seborrheic dermatitis is a common chronic inflammatory skin condition affecting 11.6% of the general
population and up to 70% of infants in the first few months of life.[1] It can impact the psychology and
quality of life of those suffering from chronic relapsing course.[2,3,4] Chronic skin diseases can have
physical and emotional impact on one's qualities of life which include discomfort, stigmatization, loss of
self-esteem, and limitations in social activities.[5] Some even have a negative impact on the quality of life
comparable to that of cardiovascular diseases.[6]
Scalp pruritus and scales of seborrheic dermatitis may form social stigma and cause isolation from the
society. Facing these stressful circumstances was proposed to increase depressive symptoms in this group
of patients.[2] However, limited studies have been conducted to access the clinical characteristics of the
disease and quality of life of the patients. Few studies[3,7] have been conducted in temperate climates
where clinical characteristics of patients may differ from those in tropical countries. Therefore, the aim of
this study was to investigate the clinical characteristics and quality of life of patients with seborrheic
dermatitis in Thailand, which has a tropical climate.
Methods
Study design A cross-sectional study was performed at a university-based hospital and tertiary referral
center in Bangkok, Thailand, between May 2013 and June 2014. The study was approved by the
institutional review board.
Participants Patients who were older than 18 years[3] and had been diagnosed with seborrheic dermatitis
at any site were included. Diagnosis of seborrheic dermatitis was made clinically by presentation of
erythematous patches with greasy scales on predilection areas including the scalp, face, ears, presternal or
intertriginous areas.[8] Additional laboratory investigations including potassium hydroxide (KOH)
examination or antinuclear antibodies (ANA) were performed in case of uncertain diagnosis to rule out
other dermatologic diseases. Doubtful cases and those with other concomitant dermatoses were excluded.
All patients gave written informed consent prior to inclusion in the study.
Instruments The facial skin types were classified as dry, normal, oily, or combination skin.[9] The skin
type-related symptoms, which correlate with the causal sebum level,[9] were used to classify facial skin
types. The questions included “feeling of dryness in the face,” “feeling tightness after washing,” “feeling
coarseness after washing,” “feeling oiliness in the face,” “easy washing out of make-up” and “feeling
difference in facial oiliness in face.”[9]
The validated Thai version of the dermatology life quality index (DLQI)[10] was used to evaluate patients’
quality of life. The formal permission to use the DLQI score was kindly given to Dr. Kulthanan by Dr.
Andrew Y. Finlay. All patients were asked to complete the questionnaire by themselves. The DLQI
questionnaire comprised 10 questions with 6 domains, including symptoms and feelings, daily activities,
leisure, work and school, personal relationships, and treatment difficulties. The DLQI score was grouped
into five categories: 0–1 = no effect, 2–5 = small effect, 6–10 = moderate effect, 11–20 = very large effect,
and 21–30 = extremely large effect.[11] The DLQI score was further classified into two categories. A
DLQI score of 0 to 5 was interpreted as no or small effect on quality of life. A score of more than 5, which
equate to moderate to severe effect on quality of life, was determined as a high DLQI score.
Procedures After receiving informed consent, patients were asked to complete the DLQI questionnaire by
themselves. The demographic data and clinical information (i.e., underlying disease, personal and family
history of atopy, age of onset, course of disease, and aggravating factors) were collected. Physical
examination was performed by one dermatologist to evaluate the lesion and extent of involvement.
Statistical analysis Data were analyzed using SPSS version 17.0. Descriptive statistics, e.g., mean,
median, minimum, maximum, and percentages were calculated to describe the demographic data. The
categorical variables were compared using Pearson's Chi-square test or Fisher's exact test when
appropriate. Demographic data, clinical data and the DLQI score were compared using the Pearson's Chi-
squared test and the Mann–Whitney U test for categorical and continuous data, respectively. The mean
values were compared using ANOVA. A P value of < 0.05 was considered significant.
Results
Demographic data A total of 166 participants were included. There were 94 females (56.6%) and 72
males (43.4%). The mean (SD) age of patients was 41.9 (18.9) years, ranging from 18 to 89 years. The
mean age at diagnosis was 35.5 (19.3) years. The median time elapsed since diagnosis was 3 years. The
most reported facial skin type was combination skin, followed by oily skin. Eighty-four patients (50.6%)
were reported having a personal history of atopy. The most common atopy reported was allergic rhinitis,
followed by allergic conjunctivitis, asthma and atopic dermatitis, respectively. Sixty-five patients (39.2%)
had a family history of atopy. Demographic data are shown in Table 1.
Three patients (1.8%) in this study were infected with HIV. The mean CD4 immune cell count was 401
cells/mm3, ranging from 18 to 850 cells/mm3.
Clinical features Of all the patients, 147 (88.6%) experienced multiple episodes of eruption, while 19
(11.4%) reported having the lesions for the first time. Of those who had chronic disease, 113 patients
(68.1%) had an occasional exacerbation with a chronic recurrence, while 34 (20.5%) had a more persistent
and continuous course. Among the chronic recurrent group, the median of outbreaks was six times per
year, ranging from once every 4 years to weekly eruptions. The median eruption time was 2 weeks with a
median interval of 1.5 months. Of those with continuous course, the median duration from onset was 3
years.
The most commonly affected area was the face (75.3%), followed by the scalp (59.%), the retroauricular
area (7.8%), the upper chest (3%), and the upper back (2.4%). On the face, the nasolabial folds, eye brows,
hair line, and eyelids were commonly involved. Rashes were rare on other areas, such as inguinal and
axillae. Ninety-nine patients (59.6%) usually had localized lesions on one body part, while 67 patients
(40.4%) had multiple sites of involvement. There was no difference in the extent of involvement,
symptoms, or course of disease between the HIV and non-HIV infected groups.
Erythematous patches were found in all cases. Scale was noted in 95.2% of the patients while some treated
cases had no scale. Most seborrheic dermatitis patients usually had symptoms of itchiness (78.9%) or
burning (4.8%), while 19.3% were asymptomatic. Table 2 shows the clinical characteristics of the
seborrheic dermatitis patients.
Of 166 participants, 138 (83.1%) reported that the outbreak was triggered by exogenous and/or
endogenous factors. Variables reported to aggravate seborrheic dermatitis were seasonal factors (i.e., hot
weather) (34.9%), emotional stress or sleep deprivation (28.3%), cosmetic products (21.7%), sweat and
damp humidity (14.5%), sun exposure (14.5%), foods (12.0%), and infection (2.4%). Figure 1 shows
aggravating factors that triggered seborrheic dermatitis.
Corticosteroids were used as a first-line therapy in most patients. One hundred and fifty-four patients
(92.8%) were treated with mostly mildly potent topical corticosteroids. Moderately potent topical steroids
were also used in recalcitrant cases or some anatomical areas such as the scalp. For alternative treatments,
topical antifungal medication, tar shampoo, and topical calcineurin inhibitors were used in 51 patients
(30.7%), 44 patients (26.5%) and 1 patient (0.6%), respectively.
Quality of life All patients completed all 10 questions of the DLQI questionnaire. The mean (SD) of the
total DLQI score was 8.1 (6.0) with a range of 0 to 27. Six patients (3.6%) had a DLQI score more than 20,
which implied extremely large effect on quality of life. Of these, some experienced only mild,
asymptomatic, localized lesions. Table 3 and Figure 2 show the DLQI score of each question. Question 1
(symptom) and question 2 (embarrassment) had the highest mean DLQI score (1.5), while question 9 had
the lowest mean score (0.1).
Table 4 shows characteristics of patients categorized by the DLQI score. There was no statistically
significant difference between the two DLQI categories regarding duration of disease, extent of
involvement, symptoms or course of the disease. Mean (SD) DLQI score of first timers, chronic relapsing
and chronic persistent patients were no significant difference with the score of 8.1 (4.7), 7.7 (5.9) and 8.9
(7.3), respectively. Female gender, young age, and scalp lesions were significantly associated with a higher
DLQI score. Gender, age, duration of disease, course of disease, site of lesions, extent of involvement and
symptoms were included in a multiple logistic regression analysis; however, only the remaining factors
associated with a high DLQI score are shown in Table 5. Females significantly scored higher than males in
question 2 (embarrassment) and question 4 (clothing choice).
Discussion
The prevalence of seborrheic dermatitis is unclear due to lack of validated diagnostic criteria.[12] Some
publications report that seborrheic dermatitis is more common in men.[13,14] However, a population-
based study in the United States revealed that the prevalence of seborrheic dermatitis was estimated to be
higher in women (3%) than men (2.6%).[12,15] This paper also showed that most of seborrheic dermatitis
patients in the study were female.
Seborrheic dermatitis has two peak prevalence: infantile and adult.[14] In adult seborrheic dermatitis, the
peak prevalence is approximately 30 to 60 years of age.[3,14] The mean age of patients in this study was
41.9 (SD = 18.9) years. The mean age of onset was 35.5 (19.3). Regarding gender ratio, mean age of onset
and median range of outbreak, the data was comparable to the previous study in Spain.[3]
The subjective facial skin type was found to be comparable to sebum production levels with the
appropriate questions, and the sebum level was highest in the oily skin type, followed by combination,
normal, and dry skin.[9] In this study, most patients had combination skin, followed by oily skin, dry skin,
and normal skin. The role of seborrhea in seborrheic dermatitis is debatable. One study[16] demonstrated
increased sebum production levels in seborrheic dermatitis patients, while others[17,18] found normal, or
even decreased rates of sebum production in seborrheic dermatitis. Although the correlation between
sebum levels and pathogenesis of seborrheic dermatitis is unclear, there is evidence that lipid composition
in seborrheic dermatitis patients differs from unaffected controls.[13]
Half of patients in this study reported having a personal history of atopy. This involved either allergic
rhinitis, allergic conjunctivitis, asthma, or allergic dermatitis. In Thailand, the prevalence of allergic
rhinitis and asthma in university students was reported to be up to 23–64% and 2–17%, respectively.
[19,20,21,22] This implies that the prevalence of atopy is not elevated in seborrheic dermatitis patients.
Seborrheic dermatitis is more common in patients with Parkinson's disease, mood disorders, and those
with HIV/acquired immunodeficiency virus syndrome (AIDS).[13] In HIV-infected individuals, the
clinical severity of seborrheic dermatitis was more severe, especially in those with low CD4 counts.[12]
Due to the small number of HIV patients in this study, we found no significant association between HIV
infection and the extent of involvement, symptoms, or course of seborrheic dermatitis.
The course of seborrheic dermatitis in adults is variable. Some experience occasional exacerbation and
others may have a more persistent course with frequent recurrences.[23] This study shows that most of
patients experienced a chronic course (i.e., either chronic recurrent or persistent). The frequency of
exacerbation ranged from as long as once in every 4 years to weekly recurrences. Median number of
outbreak was six times per year, which is higher than three times per year reported in the study[3] from
temperate climate.
In this study, a majority of patients had the triggering factors that aggravate seborrheic dermatitis,
compared to 98.4% in the previous study.[3] The most common reported factor in this study was seasonal
factor (mostly summer and hot climate), followed by stress. In contrast, study from temperate climate[3]
reported stress/depression/fatigue to be the most common triggering factors followed by seasonal variables
(worsens in winter and improves in summer). As there are variable in seborrheic dermatitis-related factors
(UV radiation, humidity and temperature) during each season,[24] the different climates of the study
locations may explain the discrepancy of these results. Harsh environment (low temperature and humidity
in winter) on skin barrier is responsible for high frequency of seborrheic dermatitis in temperate countries.
[3,24] Warmth and humid climate, facilitating pityriasis fungal growth, may trigger seborrheic dermatitis
during summer month in Thailand. In addition, skin microorganisms, which are divergently colonized
among patients from different region,[25,26,27] may effect on the growth of potential pathogens and
contribute to the discrepancy of the health outcome. Although exposure to sunlight is thought to be
beneficial in seborrheic dermatitis due to inhibition of Pityrosporum ovale and Langerhans cell
suppression,[24,28] we found that sunlight was considered a triggering factor in some patients. Seborrheic
dermatitis patients have an increased risk of skin irritation to sodium lauryl sulfate, which is used in
cosmetics and household products.[13,29] In this study, cosmetic products were reported to be a triggering
factor in 21.4% of patients. It should be noted that these triggering factors were subjectively reported by
patients and a larger controlled study with objective clinical data should be further investigated.
In this study, the mean DLQI score of seborrheic dermatitis was 8.1 (SD = 6.0), which is higher than the
score of 7.73 (SD = 5.3) that was previous published.[7] The mean DLQI score of 8.1 was almost
comparable to HIV-infected patients who had a mean DLQI of 8.7.[30] Comparing to other dermatologic
diseases in Thailand, the observed mean DLQI score for seborrheic dermatitis was higher than fungal
infection (i.e., mean DLQI score of 6.5), but lower than acne (i.e., mean DLQI score of 10.6). Although
there was no statistically significant difference between the two DLQI categories regarding duration of
disease, extent of involvement, symptoms or course of the disease, this study showed that the DLQI score
was significantly higher in women than in men and in younger patients than in elderly patients. Patients
who had seborrheic dermatitis on the scalp also had significantly higher DLQI scores than those who had
lesions on other areas. This is parallel to previous studies[3,7] that used scalpdex and DLQI questionnaires
to evaluate the quality of life in patients who had scalp dermatitis, or seborrheic dermatitis with or without
other concomitant skin diseases. Scales in scalp seborrheic dermatitis can be bothersome because of
shedding flakes, which can be perceived as uncleanliness.[23] Social-image awareness may lead to a loss
of self-esteem, a negative social image, and a greater negative impact on quality of life. Therefore, when
determining treatment regimen for these specific groups of patient, a more aggressive regimen should be
employed to quickly alleviate the disease and improve patients’ quality of life.
Conclusion
Seborrheic dermatitis is a common dermatologic disease with variable course and clinical severity.
Geographic difference has some influences on clinical profiles of the disease. Although mild and
asymptomatic, seborrheic dermatitis can have a great impact on quality of life and lead to loss of self-
esteem and a negative social image, especially in young age group, female gender and scalp lesions.
What is new?
In contrast to study from temperate climate, warmth and humid climate trigger seborrheic dermatitis
during summer month in tropical country. Although mild and asymptomatic, seborrheic dermatitis can
have a great impact on quality of life, especially in young age group, female gender and scalp lesions.
Acknowledgments
We are thankful to Ms. Pimrapat Tengtrakulcharoen for her kind support.
Footnotes
Source of support: Nil
Conflict of Interest: Nil.
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Figures and Tables
Table 1
Demographic and clinical data of seborrheic dermatitis patients
Table 2
Clinical features and quality of life of seborrheic dermatitis patients
Open in a separate window
Figure 1
Aggravating factors of seborrheic dermatitis as reported by patients
Table 3
The dermatology life quality index (DLQI) score of each question
Figure 2
The mean scores of each DLQI question
Table 4
Characteristics of patients categorized by DLQI score
Table 5
Multiple logistic regression model of factors associated with high DLQI score
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1/3/2021 Clinical Characteristics and Quality of Life of Seborrheic Dermatitis Patients in a Tropical Country

Indian J Dermatol. 2015 Sep-Oct; 60(5): 519. PMCID: PMC4601435

Clinical Characteristics and Quality of Life of Seborrheic Dermatitis

Received 2014 Dec; Accepted 2015 Apr.

Copyright : © Indian Journal of Dermatology

Aims and Objectives:

Materials and Methods:

Keywords: Characteristics, DLQI, quality of life, seborrheic dermatitis

What was known?

Conflict of Interest: Nil.

5. Ahmed A, Leon A, Butler DC, Reichenberg J. Quality-of-life effects of common dermatological

7. Szepietowski JC, Reich A, Wesołowska-Szepietowska E, Baran E. National Quality of Life in

10. Kulthanan K, Jiamton S, Wanitphakdeedecha R, Chantharujikaphong S. The validity and reliability of

19. Tuchinda M. Prevalence of allergic diseases. Siriraj Gaz. 1978;30:1285–96.

20. Vichayanond P, Sunthornchart S, Singhivannusorn V. Prevalence of asthma, allergic rhinitis and

22. Kulthanan K, Jiamton S, Thumpimukvatana N, Pinkaew S. Chronic idiopathic urticaria: Prevalence

26. Thamlikitkul V, Santiprasitkul S, Suntanondra L, Pakaworawuth S, Tiangrim S, Udompunthurak S, et

Figures and Tables

Open in a separate window

Aggravating factors of seborrheic dermatitis as reported by patients

Open in a separate window

The mean scores of each DLQI question

Open in a separate window

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