Cradle cap

Cradle Cap (infantile or neonatal seborrhoeic dermatitis, also known as crusta lactea, milk crust, honeycomb disease) is a yellowish, patchy, greasy, scaly and crusty skin rash that occurs on the scalp of recently born babies. It is usually not itchy, and does not bother the baby. Cradle cap most commonly begins sometime in the first 3 months. The rash is often prominent around the ear, the eyebrows or the eyelids. It may appear in other locations as well, where it is called seborrhoeic dermatitis rather than cradle cap. Some countries use the term pityriasis capitis for cradle cap. It is extremely common, with about half of all babies affected. Most of them have a mild version of the disorder. Severe cradle cap is rare.

Causes
The cause of cradle cap is not clearly defined but it is not caused by an infection, allergy nor from poor hygiene. Possibly it has to do with overactive sebaceous glands in the skin of newborn babies, due to the mother's hormones still in the baby's circulation. The glands release a greasy substance that makes old skin cells attach to the scalp as they try to dry and fall off. There may be a relationship with skin yeasts (Pityrosporum ovale, newly renamed Malassezia furfur). Nutritionally oriented practitioners have speculated that the disorder is caused by the baby's immature digestive system being unable to absorb sufficient biotin and other vitamins of the B-complex.

Warning signs
Home remedies are appropriate with mild cases. If the condition thickens, turns red and irritated, starts spreading, appears on other body parts, or if the baby develops a persistent diaper rash, medical intervention is recommended. Fungal infection (tinea capitis) and scabies can mimic cradle cap.

Cradle cap is occasionally linked to immune disorders. If the baby is not thriving and has other problems (e.g. diarrhoea), consult a doctor.

Prognosis
Assurances that this condition will clear as the baby matures are very common. However, studies have shown that the condition not infrequently persists into the toddler years, and less commonly into later childhood. It tends to recur in adolescence and persists into adulthood. In an Australian study, about 15% percent of previously diagnosed children still had eczema 10 years later. Sometimes, cradle cap turns into atopic dermatitis. Rarely, it turns out to be misdiagnosed psoriasis.

Scalp, behind ears, eyebrows
The common advice to apply (vegetable or mineral) oil liberally to the scalp and letting it soak in overnight or for lesser periods of time seems to conflict with the fact that Malassezia yeasts thrive in oily environments. The softened scales can then be brushed away with a soft brush, toothbrush, comb or cloth, but if not done very gently, this can worsen the condition and bring about temporary hair loss. There has been no study done on these recommendations.

Applying petroleum jelly (e.g., Vaseline) liberally overnight is another popular treatment. The softened scales either fall off during the night, or can be brushed off in the morning.

Making a paste from sodium bicarbonate (baking powder) and leaving it on the affected area for 10 minutes can also help lift the scales.

There is broad disagreement regarding the role of shampoos. Some sources warn against frequent shampooing, others recommend it. Mild baby shampoo is often recommended, while never specifying what "mild" actually means. Baby shampoos often contain detergent surfactants, perfumes, quaternium-15 and other eczemagenic irritants. Again, no studies have been performed. Switching to a shampoo with the least amount of potential irritants seems prudent.

Keratolytic (dandruff) shampoos (e.g with sulphur, selenium, zinc pyrithione, or salicylic acid) are generally not recommended as they sting eyes and may worsen the dermatitis. In stubborn cases some doctors do recommend them while others warn against the use of medicated shampoos in newborns due to systemic absorption. Dandruff shampoos often contain sodium lauryl sulphate, a noted skin irritant.

Steroid and tar preparations have also been used but have significant drawbacks. Immunomodulators (tacrolimus/Protopic, pimecrolimus/Elidel) have not been approved for babies under two years.

Ketoconazole shampoos and creams are taking first place in medical treatment of moderate to serious cradle cap. Research so far indicates that this anti-fungal medication is not absorbed into the bloodstream. Unfortunately, ketoconazole shampoo is currently made with a number of problematic irritants and allergens. Using a formulation prepared by a compounding pharmacy seems like very a good idea.

There have been several studies where cradle cap cleared swiftly and completely followed by the injection of biotin, either to the baby or the breastfeeding mother. In one study, injection of B-complex worked well also. Injection directly into the vein (rather than into the muscle) is recommended. Small amounts of oral biotin have not shown efficacy in a more recent trial, and many cradle cap compendia have since said that biotin supplementation is ineffective. This is not correct. Oral supplementation with liquid biotin is favoured by some physicians, but a well-designed study is needed to ascertain the effective dosage in oral supplementation (if there is one) or the effect of injected biotin/B-complex in a larger sample. Biotin is a very safe vitamin with no known toxicity, and well worth trying.

A Swedish study found good results from massaging the scalp with small amounts of borage oil twice a day.

Other home remedies recommended in various alternative sources and parent forums are herbal washes (e.g burdock or chamomile), aloe gel, and tea tree oil (Melaleuca oil) shampoo. Tea tree oil and aloe can be sensitizers; any worsening should be an occasion to discontinue the remedy in question. Both remedies have been tested in medical trials and found useful.

Eyelids
Typical medical advice is to use diluted baby shampoo on a cotton swab to cleanse the eyelid. There is no agreement on the dilution, which ranges from a few drops to a half cup warm water, to a 50/50 mix. No studies have been performed on the efficacy or safety of this treatment. (Please note the problems with baby shampoo noted above.) In adults, a study comparing soap and baby shampoo to commercial eyelid scrubs found that patients strongly preferred not to put soap or shampoo on their eyelids. Baking soda has also been recommended (a teaspoonful in a cup of boiled water) and is well accepted by adults. Boiled warm water wash may help.

Personal views

 * infantile seborrhoeic dermatitis

Arp Milchschorf Ciemieniucha