CRADLE CAP: A CLINICAL AND THERAPEUTIC ASSESSMENT IN IRAQI INFANTS
Auther:Professor Khalifa E. Sharquie1;Adil A. Noaimi;Husa
page: 20-29
ORIGINAL ARTICLESCRADLE CAP: A CLINICAL AND THERAPEUTIC ASSESSMENT IN IRAQI INFANTS
Professor Khalifa E. Sharquie1    MD; PhD. Assistant Professor Adil A. Noaimi 2   MD; DDV; FICMS.  Dr. Husam Ali Salman 3 MD, FIBMS.1Chairman of the Scientific Council of Dermatology & Venereology- Iraqi Board for Medical Specializations. 2&3 Department of  Dermatology & Venereology, College of Medicine, University of Baghdad, Baghdad, Iraq

Correspondence: Professor Khalifa E. Sharquie , Chairman of the Scientific Council of Dermatology & Venereology-Iraqi , Board for Medical Specializations. Medical collection office, P.O. Box 61080 Postal code 12114, Baghdad, Iraq. Tel No. 00-964-15560036 . E- mail: Ksharquie@yahoo.co.uk

Running title: cradle cap clinical and therapeutic assessment, Sharquie..etal
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ABSTRACT
Background: Cradle cap is a common skin disorder that affects infants during the early weeks of life. It had been mentioned to be related to many other skin diseases like seborrheic dermatitis, psoriasis and atopic dermatitis.
Objective: To shed a light on  this disorder, its association to other skin diseases and to compare the therapeutic efficacy of a combined  equal weights of flumethasone pivalate 0.02% cream and clotrimazole1% cream once daily with that of olive oil once daily too.
Patients & Methods: This is a case series descriptive and comparative therapeutic study conducted at the Department of Dermatology & Venereology- Baghdad Teaching Hospital, during  March 2007 and March 2008. Thirty two infants with cradle cap were involved in this study. They were divided randomly into 2 groups. Group I received a combined  equal weights of flumethasone pivalate 0.02% cream and clotrimazole1% cream. Group II received olive oil. The parents instructed to apply the formula once overnight and wash the scalp at the morning and to continue the treatment till complete disappearance of the scales. Each infant was seen twice monthly till the age of 6 months.
Results:  Twenty four infants completed the study. Their ages ranged from  2 - 5 months with a mean ± SD of 3.167 ± 0.816 months. Fourteen (58.3%) infants were males and 10 (41.7%) were females. The age of onset of cradle cap was ranged from 1-3 months with a mean ± SD of 1.792 ±  0.550 months. The scale was greasy in 20 (83.33%), dry in 4 (16.66%), thick yellowish in 18 (75%) and thin whitish in 6 (25%). Twenty one (87.5%) of cases had infantile seborrhoeic dermatitis and three (12.5%) had infantile atopic dermatitis. All cases of atopic dermatitis had dry, thin and whitish scale. All (13) infants in group I showed clearance of the scale in duration ranging from 4 to 10 days with a mean  ± SD of 7.15 ± 1.86 days. All (11) infants in group II showed clearance of cradle cap in a duration ranging from 6 to 15 days with a mean  ± SD of 10.81 ± 2.40 days. There was a statistically significant difference between the 2 groups. P value = 0.0004. At the end of follow up the recurrence was higher  among group1,  but the difference was not significant P value = 0.8151. No side effects were reported from both treatment groups.     
Conclusion: Cradle cap is a common skin disorder among infants, most cases related to infantile seborrheic dermatitis and some had atopic dermatitis.
Keywords: cradle cap, clinical, therapeutic, Iraqi infants.
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INTRODUCTION


 

Cradle cap is a greasy patches of scaling on the scalp of infants manifested between the second week and sixth month of life 1,2  .Untreated, it usually resolves at 8 months 1.By some authors it was considered as a form of infantile seborrhoeic dermatitis, either alone or with involvement of inguinal, axillary and retroauricular folds 3. However cradle cap may  co-exist with atopic dermatitis 4. 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 1,5. So, for these reasons  this study was conducted to shed a light on different clinical aspects of cradle cap and to compare the therapeutic efficacy of a combined equal weights of flumethasone pivalate 0.02% cream and clotrimazole1% cream once daily with that of olive oil once daily too.  
PATIENTS AND METHODS
This is a case series descriptive and comparative therapeutic study conducted at the outpatient Department of Dermatology and Venereology - Baghdad Teaching Hospital between May 2007 and February 2008.Thirty two infants with cradle cap were involved. A full history was taken from their parents regarding age, sex, age of onset,  history of cradle cap in siblings, family history of atopy, psoriasis and seborrhoeic dermatitis, history of any disease or drug intake during pregnancy, sleep disturbance of the infant and type of feeding.Complete dermatological examination was performed for each infant at the 1st visit to see the type of the scale of cradle cap (greasy or dry), texture(thin or thick) and its color,  involvement of eyebrows, axilla, groin, umbilicus, neck, cheek and extremities with erythema and / or scales. Skin also was examined for any evidence of a generalized dryness. For each infant a formal consent was taken from the parent, before starting therapy, after full explanation regarding: nature of disease, course,  method of treatment, duration and follow up. Also the ethical approval was performed by the scientific committee of the Scientific Council of Dermatology &Venereology-Iraqi Board for Medical Specializations. A photograph was taken at the initial and subsequent visits by a mercury digital camera cyberplx  S-450V at the same place and a fixed illumination.The infants were divided randomly into 2 groups:Seventeen infants to receive a mixture of an equal weights of flumethasone pivalate (locarten from Novartis) 0.02% cream and clotrimazole (fugidine from SDI)1% creams. Fifteen infants to receive olive oil. The parents instructed to apply the treatment once over night  and wash the scalp at the morning and to continue treatment till complete disappearance of the scales. Each infant was seen twice monthly till the age of 6 months to record any side effects, to see the time of disappearance of the cradle cap and if there was a recurrence of the scale. Also to watch any evidence of atopic dermatitis at the age of 6 months.The presence of infantile dermatitis at the age of 6 months  is most definite for atopic dermatitis than seborrhoeic dermatitis (3). The diagnosis of atopic dermatitis was according to the refined criteria of Hanifin and Rajka which are validated for adults and children 6.Statistical analysis was done by using  Unpaired t- test  to compare the  duration of clearance of scales for both    groups of treatment. P value of less than 0.05 was considered significant. Also, Chi-square with Yates correction was used at the end of follow up to compare the recurrence of cradle cap between the 2 groups. P value of less than 0.05 was considered significant 
RESULTS
Part I:
Eight infants defaulted from the study after 1-2 months of follow up. Twenty four infants with cradle cap were completed the study, their ages ranged from 2 - 5 months with a mean ± SD of 3.167 ± 0.816 months. Fourteen (58.3%) infants were males and 10 (41.7%) were females. The age of onset of cradle cap was ranged from 1-3 months with a mean ± SD of 1.792 ±  0.550 months. The  information obtained from history were shown in ( Table- 1).  The findings were reported at the 1st visit were shown in (Table- 2).Part II:Twenty four infants completed the study in the 2 treatment groups:Group1- Thirteen infants were treated with a mixture of an equal weight of   flumethasone pivalate 0.02% cream and clotrimazole1% cream. Group 2- Eleven infants treated with olive oil.Group I: All infants showed clearance of the scale of cradle cap in a duration ranging from 4 to 10 days with a mean ± SD of 7.15 ± 1.86 days. (Figure- 1A & B)Group II: All infants showed clearance of the scale of cradle cap in a duration ranging from 6 to 15 days with a mean ± SD of 10.81 ± 2.40 days. (Figure- 2A & B)There was a statistically significant difference between the 2 groups. P value = 0.0004; At the end of follow up the recurrence was higher  among group1,  but the difference was not significant P value = 0.8151No side effects were reported from both treatment groups. Re evaluation of infants at the age of 6 months revealed the followings: table (3) 
Figure 1: A five months old infant with a cradle cap for 2 months.
A)    Before treatment. There is a thin whitish scale.B) One week after treatment with a combined flumethasone pivalate + clotrimazole
  
Figure 2: A four months old infant with a cradle cap for 2 months.
A) Before treatment. There is a thick yellowish scale.B)     Two weeks after treatment with olive oil. 
   


DISCUSSION

Cradle cap is one of the 3 most common dermatoses in infancy, which are cradle cap, diaper or primary contact dermatitis and atopic dermatitis 7.  In this study the mean age of onset of cradle cap was 1.79 months, this was comparable to other studies that had mentioned that cradle cap age of onset highest in the 1st 3 months 8.Cheeks erythema was seen in 5 (20.83%) of affected infants, 3 of them had dry skin and family history of atopy. Those 3 infants fitted the refined criteria of Hanifin and Rajka for the diagnosis of atopic dermatitis. So, all infants in our study with atopic dermatitis had cheeks erythema,  but not necessarily all infants with cheeks erythema  having atopic dermatitis.The family history of atopy was reported in 6 (25%) of infants, but only 3 (12.5%) were diagnosed as atopic. This mean that family history of atopy does not always helpful in distinguishing seborrhoeic from atopic dermatitis. This was similar to other study (10).Two infants showed a thick cradle cap and a well demarcated psoriasiform   napkin erythema. One of them still having this erythema at the age of six months and because both of them had no family history of psoriasis, they were probably represented a psoriasiform seborrhoeic dermatitis.The striking feature was that the scale of cradle cap was dry, thin and whitish in atopic infants, while it was greasier, thicker and yellowish in cases of seborrhoeic dermatitis. This might be due to the fact that cases of infantile seborrhoeic dermatitis secrete some sebum in the first few weeks of life and that the early resolution of the disorder was probably related to decreasing levels of sebum production 11.To the best of our knowledge the type, texture and color of scales of cradle cap in relation to infantile seborrhoeic or atopic dermatitis was not mentioned previously. A part from cases that were diagnosed as atopic, all other cases of cradle cap have one or more of features of infantile seborrhoeic dermatitis (eyebrows scaling, napkin fold erythema, and axillary erythema). So in conclusion the thin, dry and white quality of cradle cap scale and generalized skin dryness are 2 important determinants for the development of infantile atopic dermatitis.Also a cradle cap is not a specific diagnosis, however the majority of cases were belong to infantile seborrhoeic dermatitis and around 12 % were related to atopic dermatitis. Many studies have noted a potential link with increased concentrations of the yeast Malassezia furfur (formerly Pityrosporum ovale), but a causative relationship 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, 5. Cradle cap is highly amenable to treatment, moisturizers have an important role in softening scale, yet baby oil alone was mentioned to be not insufficient. Greaser emollients may not be cosmetically acceptable 4.So we did a comparative trial between olive oil and a steroid- antifungal combination cream which is more acceptable than greasy base.Infants treated with a combination of (flumethasone pivalate 0.02% cream and clotrimazole1% cream) showed mean duration of clearance of cradle cap of 7 days.   This was considered a short and acceptable period to the compliance of parents with a minimal expected risk of adrenocortical suppression.The response  to a such  combination looks better than that of other study in which once-daily ketoconazole 2% cream was used. Seventy nine % of infants affected with seborrheic dermatitis of the scalp and diaper area showed good response by day 10 9. Another comparative study was conducted on 2% ketoconazole cream and 1% hydrocortisone cream in the treatment of infantile seborrheic dermatitis revealed no statistical difference. All skin lesions in both treatment groups were cleared by the end of the second week of treatment 2. This approximately twice the time needed for clearance compared to our study which was around 1 week.So steroid- antifungal combination might have synergistic effect resulting in clearance with a shorter time because it suppresses both inflammation and the yeast Malassezia furfur that might play a role in seborrhoeic dermatitis 1, 2.Olive oil also resulted in an acceptable resolution of cradle cap with comparable results to the above studies. It was safe therapy which resulted in loosening of the scales to be easily washed and don’t have risks of topical steroids and associated with lower recurrence rate compared to steroid-antifungal agents, but without significant difference.Although there was a better response of a combined flumethasone pivalate 0.02% and clotrimazole1% creams  than olive oil with significant difference, still we can recommend to use the olive oil especially that most people knew that this remedy was useful. In over stressed parents whom need quick clearance of their infants scales a combination of flumethasone pivalate 0.02% and clotrimazole1% creams can be recommended. In conclusion cradle cap is mostly part of seborrhoeic dermatitis rather than atopic dermatitis and steroid-antifungal combination cream was an effective mode of therapy.

 

REFERENCES

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9.      Taieb A, Legrain V, Palmier C, Lejean S, Six M,Maleville J.Topical      ketoconazole for infantile seborrhoeic dermatitis.Dermatologica     1990;181:26–32

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