Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Seborrhea of the Scalp (Cradle Cap)
An inflammatory, scaling eruption of the scalp.
I. Etiology
A. Presumed to be accelerated epidermal growth
B. Although it occurs in an area with large numbers of sebaceous glands, there is no documented proof that it is caused by increased sebum production.
II. Incidence: Occurs predominantly in newborns and adolescents.
III. Subjective data
A. Pruritus
B. Scaling of the scalp
C. Dandruff
D. Often no presenting complaints; nurse practitioner may find it on routine physical examination.
IV. Objective data
A. Scalp is primary site.
1. Slight to severe erythema
2. Yellowish, greasy scales
3. Excoriations from scratching
B. Check entire body, because seborrhea may progress to other areas.
1. Face: Erythema and scaling may progress to forehead, eyebrows, eyelashes (marginal blepharitis), and cheeks.
2. Ears: Dryness, scaling, erythema, and cracking in postauricular areas
3. Back of neck, groin, umbilicus, and gluteal crease may also have erythema and fine, dry scaling.
4. Secondary infection may occur.
V. Assessment
A. Diagnosis is generally made by the typical clinical picture of a yellowish, greasy, crusted dermatosis of the scalp in an infant; in an older child, by erythema and scaling of the scalp.
B. Differential diagnosis
1. Tinea capitis: Round lesions with broken hair stumps
2. Tinea corporis: Erythematous, circinate, or oval scaling patches
3. Psoriasis: Erythematous macules or papules covered with dry, silvery scales
4. Atopic dermatitis: Family history of atopy
VI. Plan
A. Infants: Cradle cap
1. Rub petroleum jelly or mineral oil into scalp to soften crusts 20 to 30 minutes prior to shampoo.
2. Shampoo daily with baby shampoo, using a soft brush.
3. If lesions are inflammatory or extensive, use 1% hydrocortisone cream bid.
B. Toddlers or adolescents: Seborrhea of the scalp
1. Antiseborrheic shampoo 2 to 3 times a week: Selsun, Exsel, or Nizoral
2. Shampoo on alternate days with nonmedicinal shampoo.
3. If lesions are inflammatory or extensive, use low potency topical corticosteroid lotion daily.
C. Seborrheic blepharitis (see Marginal Blepharitis, p. 341)
D. Lesions on areas other than scalp: 1% hydrocortisone cream tid–qid
VII. Education
A. Stress prevention
B. Teach mothers of newborns how to shampoo and rinse hair.
C. Reassure that it is all right to wash over “soft spot.”
D. Daily shampooing is recommended.
E. Keep shampoo out of eyes.
F. Do not use prescription shampoos if child is not cooperative or any sensitivity results.
G. Continue treatment for several days after lesions disappear.
H. Use antiseborrheic shampoo at least weekly once resolved.
I. If lesions have spread to forehead and eyebrows, vigorous successful treatment of scalp will generally result in clearing of the face.
J. Seborrhea generally disappears by 6 months but may recur at puberty.
K. Seborrhea cannot be cured, but it can be controlled.
L. Seborrhea does not cause permanent hair loss or baldness unless head becomes grossly infected.
VIII. Follow-up: Telephone call in 5 to 6 days to report progress; return to office if no improvement.
IX. Consultation/referral
A. Secondary impetigo
B. No response to treatment in 10 to 14 days