• Main goals: reduce Malassezia, control inflammation, and prevent recurrence.
• Scalp flare: ketoconazole 2% shampoo 2–3×/week for 2–4 weeks, leaving it on for approximately 3–5 minutes before rinsing.
• Alternative: ciclopirox shampoo, according to the available formulation.
• Significant scalp inflammation: briefly add an appropriate topical corticosteroid formulation such as a solution, foam, or oil.
• Face/trunk flare: ketoconazole 2% cream once or twice daily for 2–4 weeks.
• Significant facial inflammation: hydrocortisone 1–2.5% once or twice daily for only a few days, minimizing corticosteroid exposure on facial skin.
• Tacrolimus or pimecrolimus may be used as steroid-sparing alternatives, particularly for facial disease or frequent recurrences.
• Scalp maintenance: antifungal shampoo approximately once weekly, adjusted according to recurrence frequency.
• Facial maintenance: intermittent topical antifungal therapy; a topical calcineurin inhibitor may be considered for frequent recurrences.
• Avoid prolonged use of potent topical corticosteroids, particularly on the face and skin folds.
• Severe or refractory disease should be managed individually by a dermatologist; systemic antifungal therapy may occasionally be considered.
