The Potential Additive Benefits of the Combination of Selenium Sulfide and Salicylic Acid in Dandruff and Seborrheic Dermatitis Treatment

Introduction

Seborrheic dermatitis is characterized by red scaly lesions primarily spread across the scalp, face, upper trunk, nasolabial folds, presternal and interscapular regions, axillae, and the groin region. (1) It is seen more frequently than expected in patients with pityriasis versicolor, Malassezia folliculitis, and immunocompromised conditions. (1) Along with a genetic predisposition, mental stress and dry air may aggravate the disease. (2) In study by Araya et al 34.9% of patients with SD reported hot weather as a trigger for their outbreaks, while 14.5% cited sweat and damp humidity, and another 14.5% mentioned sun exposure as disease exacerbating factors highlighting the role of temperature and humidity. (3) Given that species of Malassezia multiply more quickly under high humidity, it is plausible that in conditions that are conducive to Malassezia growth, the interactions between climate variables and the organism's growth could create a vicious cycle. (4)

Understanding the multi-faceted pathogenesis

The hyperproliferation of the dermal squamous epithelium in seborrheic dermatitis causes imperfect keratinization and faulty desquamation of the cornified layer in 3 days instead of the usual 25-30 days. (5) Recolonization causes the disease to recur, but improvement in the condition corresponds with a decrease in the number of Malassezia. (6) It is suggested that fungal metabolites interact with triglycerides from sebaceous glands, producing inflammatory mediators, which is consistent with the observation that the condition predominates in sebum-rich areas. (7) Another theory proposes that the lipid coating of the fungus induces keratinocytes to produce proinflammatory cytokines, resulting in inflammation and skin eruptions. (8) Despite these theories, there is no clear correlation between the quantity of fungal organisms and the severity of the disease. (9) Majority of the publications concur that the three primary prerequisites of the pathophysiology of SD are as follows: infestation by Malassezia, sebaceous glands secreting lipids, and underlying immunological system susceptibility. (10–13) The more severe form of dermatitis can develop due to an additional infection caused by pathogenic strains of micrococci, typically Micrococcus pyogenes var. aureus and Micrococcus pyogenes var. Albus. (14)

There are five distinct phases to the pathogenesis.

1. This begins with the secretion of lipids onto the skin's surface via sebaceous glands. (12,15,16)

2. Followed by lipid coating in areas that are colonized by Malassezia. (11,12,17,18)

3. Malassezia secretes lipase, which causes the production of lipid peroxides and free fatty acids (FFA), which trigger the inflammatory response. (12,19,20)

4. This in turn causes the immune system to produce cytokines such as TNF-α, IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, and IL-12, which promotes the differentiation and proliferation of keratinocytes. (21–24)

5. Ultimately, the process causes the disruption of the skin barrier leading to clinically noticeable erythema, pruritus, and scaling. (25–27)

Figure 1: Explains the pathogenesis of Seborrheic Dermatitis and how the combination of Selenium Sulfide and Salicylic Acid help target the pathogenesis of Seborrheic dermatitis.

The effectiveness of antifungal medications in treating seborrheic dermatitis provides the majority of the data supporting the causal role of Malassezia yeasts. (28) The treatment for SD’s persistent relapsing course requires systemic and topical antifungal options. Relapses necessitate intermittent treatment whereas long-term maintenance is required to preserve remission. (29) In clinical practice, treatment failure with azole antifungals has been observed due to M. globosa and M. restricta strain resistance. (30) This amplifies the need to find new treatment agents for Seborrheic dermatitis.

The Potential Benefits of combining Selenium Sulfide and Salicylic Acid:

The main treatment goals for managing SD revolve around reducing troublesome symptoms like pruritus and eradicating the visible signs of the disease. (31) Itching or redness on the scalp in a patient with facial SD necessitates treatment at both locations, as the face and scalp are the most commonly affected areas. (32) These treatment goals can be effectively addressed using a combination of selenium sulfide and salicylic acid.

Across the 5 phases of the pathogenesis of Seborrheic dermatitis, Selenium sulfide and Salicylic acid step in the 3rd and 5th phases respectively. In the third phase, selenium sulfide inhibits the growth of Malassezia and reduces lipase secretion thereby depleting the production of free fatty acids and lipid peroxides. Whereas in the fifth phase, Salicylic acid soothes the disruption of the skin barrier by reducing scaling and redness. This dual mechanism of action demonstrates how selenium sulfide and salicylic acid specifically address key aspects of SD pathogenesis, providing a systematic approach to treatment.

Selenium disulfide can also be used against Malassezia furfur as it has antifungal properties. (33) Being an anti-infective drug, selenium sulfide functions by slowing the rate at which the infection-causing yeast grows. Skin irritation, dry skin, oily or dry hair, and transient hair loss are some of its adverse effects. Through thorough rinsing of hair after each treatment, hair discolouration can be minimized. (34) In cases of seborrheic dermatitis and dandruff, it is also a demonstrated cytostatic drug that inhibits the proliferation of both hyperproliferative and normal cells. (35) Cyctostatic compounds are target-specific and less toxic since they don’t affect the growth of normal cells while restraining the growth of abnormally differentiated cells. The study conducted by Barve et al. showed the high cytostatic and low cytotoxic potential of selenium sulfide. (36) Other factors that may play a part in its effectiveness is the presence of mild antibacterial and antifungal activity. (37) The anti-mitotic mechanism of action helps in reducing the rate of incorporation of thymidine into the DNA of dermal epithelial cells, which ultimately results in a reduction in the turnover of epidermal cells. (37) Patients should be counselled against using strong keratolytic preparations or excessive scratching of their lesions to prevent aggravating their condition. (2,38)

Salicylic acid is a potent keratolytic agent which lowers the skin's pH, leading to hydration of keratin and enlargement of corneocytes. Additionally, it facilitates desquamation by solubilizing the intercellular cement substance in the stratum corneum. Salicylic acid has no effect on the basal keratinocytes' rate of mitosis but is has a mild anti-inflammatory and anti-pruritic effect. The keratolytic action of the salicylic acid increases the amount of moisture in the skin and dissolves the substance that makes the cells clump together which causes the skin to shed dead cells from its top layer. (39) Shedding the skin cells, softening the top layer of the skin, and decreasing scaling and dryness are made easier by this effect. (37) Softening of the top layer of the skin is possible due to this complex and eventually eases the shedding of dead skin cells at the superficial skin layer. (37) This helps in turning over the skin more easily and allows new cells to appear on the surface more readily. (40) It also exhibits anti-inflammatory properties by preventing the synthesis of prostaglandin. (41) Additionally, it is acknowledged for its mild antibacterial properties, it exhibits mild antibacterial properties with potency ranging from 2000-64,000 µg/mL.These properties help alleviate inflammation and reduce the growth of bacteria on the skin's surface. (42–44)

Conclusion

Seborrheic dermatitis can be comprehensively managed using the combination of selenium sulfide and salicylic acid. The flaky skin and itchiness accompanied with seborrheic dermatitis can be mitigated with the combination of keratolytic agent of salicylic acid and the antifungal properties of selenium sulfide. (37,45) Selenium sulfide's multifaceted actions, coupled with salicylic acid's exfoliating properties, results in a comprehensive treatment that effectively reduces inflammation, pruritus, and desquamation. (31) This comprehensive alleviation of symptoms may not only improve the physical appearance of the scalp but can also enhance the overall patient comfort and quality of life. (46)

For the use of a registered medical practitioner or a hospital or a laboratory only

IND2327602 02 Sept 2024

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