Snapshot A 40-year-old man with history of HIV infection presents to the clinic with a red, flaky rash around his scalp, face, nose, and ears. He has tried low-dose topical steroids, which have not helped. He would like stronger therapy for his rash. Introduction Common, chronic, inflammatory skin disease that results from oversecretion of sebaceous material hypersensitivity to superficial fungi, Malassezia fufur (formerly Pityrosporum ovale) Affects all ages “dandruff” in adults “cradle cap” in infants More severe in patients with neurologic disease (traumatic brain injury, Parkinson’s disease, stroke) HIV patients Presentation Symptoms most commonly “dandruff” in hair and face burning, itchy, scaling if severe, can become exfoliative erythroderma (as in those with immunodeficiencies) Physical exam scaly, greasy, flaky skin on scalp margins and face erythematous especially where sebaceous glands are numerous eyebrows nasolabial folds external ear canals groin Evaluation Diagnosis is made by clinical history and exam skin biopsy typically not necessary KOH prep to rule out fungal infection if resistant or suspicion for other fungal infections Differential Fungal infection Cutaneous lupus Acne rosacea Treatment Medical management topical therapies for mild disease best initial therapy: emollients and non-medical shampoos (zinc containing) low-potency topical steroids (e.g., hydrocortisone) topical antifungals (e.g., ketoconazole or selenium sulfide) selenium or zinc pyrithione or tar shampoo systemic therapies for severe or resistant disease oral antifungals (e.g., ketoconazole) oral steroids Prognosis, Prevention, and Complications Prognosis most infections respond well to therapy may recur, especially in immunocompromised individuals Prevention shampoos mentioned above work well if used properly good skin hygeine Complications can become secondarily infected with bacterial, fungal, or viral agents