Seborrheic dermatitis in the ears

What does it look and feel like?

The scale can be dry and white or yellowish, oily and sticky. The skin underneath can look mildly red, but visible redness is not essential. Itching is common, and increased itching can accompany infection. Similar patches on the scalp, eyebrows or around the nose help explain why an ear rash is not always an isolated problem.4

On darker skin, the rash can look pink, slightly purple or lighter than the surrounding skin rather than red. Seborrheic dermatitis involves inflammation, meaning swelling and changes in skin colour. Dandruff is a milder scalp condition without that inflammation; flakes around an ear are not automatically just dandruff in a different location.5

Why does seborrheic dermatitis affect the ears?

Seborrheic dermatitis favours areas with more oil glands. Its exact cause is unknown, but oil gland activity, Malassezia yeasts that normally live on skin, changes in the skin's protective barrier and genes can contribute. Stress, fatigue and weather extremes are associated with the condition. Having yeast on the skin alone does not explain every itchy ear.4

Could the rash be something else?

Contact dermatitis, other forms of eczema and infections can also affect ear skin. Contact allergy can involve perfume, hair dye, nickel or rubber; irritant dermatitis can result from soaps, detergents and abrasives. Tell the clinician which products touch your ears and whether a new product preceded the rash. An examination and detailed history are often enough to identify dermatitis. When needed, patch testing checks for contact allergy, a skin swab checks for infection, and a scraping helps exclude a fungal infection that resembles dermatitis.6

How do you treat the skin around the ears?

1. 1Cleanse the affected outer skin once or twice daily with a non soap cleanser. This skin routine is separate from cleaning inside the ear canal.
2. 2For diagnosed seborrheic dermatitis, ketoconazole or ciclopirox cream is commonly applied once daily for 2 to 4 weeks. Follow the directions for the prescribed product.
3. 3A clinician can add hydrocortisone cream for an inflamed flare, commonly up to twice daily for 1 or 2 weeks. Follow the prescribed duration rather than continuing it indefinitely.
4. 4If the outer skin feels dry, use an emollient, a moisturiser that softens dry skin. General dermatitis care includes applying one after washing or whenever the skin feels dry.

A non soap cleanser is enough for washing the affected outer skin, so the bathroom does not need a second job as a chemistry lab.2

If you also have scalp symptoms, medicated dandruff shampoo can treat flaking and dryness. Choose one labelled for dandruff or seborrheic dermatitis and follow its instructions. Dandruff shampoos have different jobs, which is why the word "dandruff" is not a complete set of instructions. Some control yeast, while others reduce scale. A dermatologist can recommend shampoo for affected skin elsewhere, but a scalp shampoo routine is not an ear canal treatment.47

What if the itching is inside the ear canal?

An inflamed ear canal is called otitis externa. It can be linked to a skin condition, but infection is a common cause. Pain, discharge and swelling are characteristic signs; swelling can also cause a blocked feeling or reduced hearing. Pain that worsens when the ear moves or during chewing can occur. These symptoms need assessment rather than assuming that every episode is the same skin flare.3

Avoid scratching or manipulating the canal with fingernails, cotton swabs or other objects. Excess moisture and trauma damage its natural defences. Earwax helps protect the canal from water and microbes, so removing it mechanically can create problems rather than solve them. Hearing aids and ear plugs can also contribute to canal trauma.3

Do not flush an inflamed ear yourself. Before flushing is considered, the eardrum must be fully visible and confirmed intact; a small hole can otherwise be missed. Flushing through a damaged eardrum can injure hearing and balance structures. If swelling, discharge or debris blocks the canal, a clinician can assess how to remove it safely. Severe swelling sometimes requires a special wick to allow prescribed medication to reach the canal.3

What other treatments can a dermatologist use?

Frequent need for steroid treatment deserves a review of the plan. Prolonged steroid use can cause skin thinning and visible small blood vessels. A dermatologist can consider pimecrolimus or tacrolimus instead. Treatment for widespread or resistant disease can involve other prescription medicines, rather than repeatedly extending the same cream course.2

How long does treatment take, and will it return?

Treatment aims to reduce scale, itch and swelling, then prevent further flares. In studies of seborrheic dermatitis, pimecrolimus and tacrolimus reduced symptoms within 2 weeks. In a roflumilast trial, 68.3% of patients had clear or almost clear skin within 8 weeks. These are results for seborrheic dermatitis treatment generally, not a timetable for clearing an individual ear rash.7

Seborrheic dermatitis is not contagious, and there is no cure. In teenagers and adults, it can settle or continue with flares for years. Winter, early spring and stress are common flare patterns. After the rash improves, the treatment plan can change to maintenance rather than continuous flare treatment. Avoid scratching: untreated scale can thicken, and scratching can lead to infection.5

When should you seek medical care?

• Contact a clinician if self care or nonprescription treatment is not helping.
• Arrange assessment if patches drain fluid or pus, form crusts, or become very red or painful.
• Have ear canal pain, discharge, swelling, a blocked feeling or reduced hearing examined.
• Seek review for treatment related burning or irritation rather than adding more products to the affected skin.