EVIDENCE-BASED ANSWER
Ketoconazole (Nizoral) shampoo appears to be a safe and efficacious treatment for infants with cradle cap (strength of recommendation [SOR]: C, consensus, usual practice, opinion, disease-oriented evidence, and case series). Limit topical corticosteroids to severe cases because of possible systemic absorption (SOR: C). Overnight application of emollients followed by gentle brushing and washing with baby shampoo helps to remove the scale associated with cradle cap (SOR: C).
Clinical commentary
If parents can’t leave it be, recommend mineral oil and a brush to loosen scale
Valerie J. King, MD, MPH
Oregon Health Sciences University, Portland
Cradle cap is distressing to parents. They want everyone else to see how gorgeous their new baby is, and cradle cap can make their beautiful little one look scruffy. My standard therapy has been to stress to the parents that it isn’t a problem for the baby.
If the parents still want to do something about it, I recommend mineral oil and a soft brush to loosen the scale. Although no evidence supports this, it seems safe and is somewhat effective.
This review makes me feel more comfortable with recommending ketoconazole shampoo when mineral oil proves insufficient. For resistant cases, a cute hat can work wonders.
Evidence summary
Cradle cap is a form of seborrheic dermatitis that manifests as greasy patches of scaling on the scalp of infants between the second week and sixth month of life.1,2 Untreated, it usually resolves at 8 months.1 It’s generally nonpruritic and doesn’t bother the infant, though it can be a stressor for parents.1
Researchers have noted a potential link with increased concentrations of the yeast Malassezia furfur (formerly Pityrosporum ovale), but a causative mechanism has not been identified.1,2 Overnight use of emollients such as mineral oil to soften scales followed by gentle brushing and washing with baby shampoo is an accepted treatment, although no trials could be found to show its efficacy for infants.1,3
Numerous treatments for seborrheic dermatitis with proven efficacy for adults have been adopted for use for infants. These include topical antifungals, anti-dandruff shampoos with zinc pyrithione or selenium sulfide, coal tar preparations, and episodic topical corticosteroids.1,4 Although each of these agents is used for infants with cradle cap, significantly sized randomized controlled trials in this age group are essentially absent.
Although limited evidence exists for seborrhea treatment in any age group, ketoconazole shampoo appears to be backed by the strongest evidence. For example, an uncontrolled multicenter trial with 575 adults found ketoconazole shampoo was superior to placebo for treatment of scalp seborrheic dermatitis with an 88% “excellent response” rate (P<.0001, no relative risk or confidence intervals given).4