Seborrhoeic dermatitis and cradle cap — formative SAQs

SAQ 1 (10 marks) — The six-week-old with the greasy yellow scalp scale

Stem: A six-week-old boy is brought to the general practice with a yellow, greasy, crusty layer over his scalp for two weeks. He is feeding well, gaining weight, and smiling, and he is not scratching or irritable. The scale sits over the vertex and the anterior fontanelle, with a little behind the ears and in the eyebrows, and there is a faint salmon-pink patch in the napkin folds. The parents are anxious that he has an infection and have borrowed a potent steroid cream. Outline your assessment, your management, and your discharge counselling. ^{[1] [5]}

Model answer

Assessment and diagnosis (3 marks). This is the classic presentation of the infantile seborrhoeic dermatitis, or the cradle cap. The decisive features are the three signatures: the greasy yellow scale rather than the dry eczematous scale, the involvement of the napkin folds that the atopic dermatitis characteristically spares, and the absent pruritus — the infant is well and settled and does not scratch. The diagnosis is clinical, no swab or scraping or blood test is required, and the well appearance and the normal growth argue against the red-flag deterioration. The borrowed potent steroid is stopped at once. ^[5]

Management — the gentle scalp care (5 marks). The first and the central element is the reassurance: the condition is common, benign, and self-limiting, it is neither an infection nor a hygiene problem nor a contagion, and it clears by six to twelve months. The scale is softened with an emollient or a vegetable oil such as the olive or the almond oil, left for fifteen minutes to a few hours, loosened with the gentle brushing, and washed with the mild baby shampoo. The picking and the harsh scrubbing are avoided. The Victoire 2019 Cochrane review found the very low-certainty evidence for the active treatments and the favourable prognosis regardless of the intervention, and it noted that no trial had tested the mineral oil, the salicylic acid, or the antifungal. The ketoconazole two per cent shampoo and the hydrocortisone one per cent are reserved for the refractory or the extensive case, not the classic one. ^{[1] [6]}

Discharge counselling (2 marks). The family is counselled that the cradle cap is benign, that the sebum and the Malassezia yeast rather than the hygiene drive it, and that it clears by six to twelve months. They are shown the gentle scalp-care technique and told to avoid the picking and the potent steroid. The safety-net advice is to return if the eruption generalises into the erythroderma, if the infant becomes unwell or fails to thrive, or if the disease persists or worsens beyond infancy. No follow-up is needed in the classic case. ^{[5] [1]}