STUDY

The Frequency of Common Skin Conditions

in Preschool-aged Children in Australia
Seborrheic Dermatitis and Pityriasis Capitis (Cradle Cap)
Peter Foley, MD, FACD; Yeqin Zuo, MB, GradDipEpidemBiostat, MPH; Anne Plunkett, BN, MPH;
Kate Merlin, BMRA, GDipHSc (Health Promotion and Health Education); Robin Marks, MBBS, FACD

Objective: To determine the prevalence and severity of
seborrheic dermatitis and pityriasis capitis in Australian
preschool-aged children.
Design: A stratified cross-sectional skin survey using
cluster sampling of centers throughout Victoria, Aus-
tralia.
Setting: The study population included children at-
tending child care centers, preschools, and Maternal and
Child Health Centers, with the reference population being
Australian children 5 years and younger.
Participants: Of the 1634 children in the original sample,
1116 children aged 11 days to 5 years 11 months were
included in the study.
Intervention: Parents completed a questionnaire re-
cording demographic information and personal and fam-
ily history of skin problems and related diseases. A der-
matologist performed a total skin examination, including
the diaper area for children younger than 12 months.
prevalence rates and site and severity of seborrheic der-
matitis and pityriasis capitis were measured.
Results: The overall age- and sex-adjusted prevalence
of seborrheic dermatitis was 10.0% (95% confidence in-
terval [CI], 8.2%-11.7%): 10.4% (95% CI, 7.8%-12.9%)
in boys and 9.5% (95% CI, 7.0%-12.0%) in girls. This was
highest in the first 3 months of life, decreasing rapidly
by the age of 1 year, after which it slowly decreased over
the next 4 years. Most (71.9%) had disease classified as
minimal to mild. Pityriasis capitis occurred in 41.7% (95%
CI, 38.8%-44.6%) of the 1116 children examined, with
85.8% categorized as minimal to mild only.
Conclusions: Seborrheic dermatitis and pityriasis capi-
tis are common in early childhood. Most children have
minimal to mild disease that would require little if any
treatment. Education programs directed at those caring
for preschool-aged children are needed to provide infor-
mation on simple preventative measures and treatment,
if necessary, that could easily reduce the morbidity as-
sociated with these very common conditions.

Main Outcome Measure: The age- and sex-specific Arch Dermatol. 2003;139:318-322

From the Department of
Medicine (Dermatology),
The University of Melbourne,
St Vincent’s Hospital
Melbourne, Fitzroy, Australia.
The authors have no relevant
financial interest in this article.
S
EBORRHEIC DERMATITIS and
pityriasis capitis (cradle cap)
are said to be common in in-
fancy and decrease in fre-
quency with increasing age.
Nevertheless, there is some debate about
the true nature or even existence of these
conditions.1,2 Hence, their frequency in
population-based studies is rarely re-
ported. In one study from the United
States, a prevalence of 9.6 per 1000 per-
sons aged 1 to 5 years was reported.3 In
pediatric clinics its relative frequency has
varied from 2.2% to 4.0% of all problems
seen or 4.5% of problems seen in chil-
dren younger than 6 years.4,5
The major textbooks of dermatol-
ogy state that seborrheic dermatitis may
be common, but they frequently assert that
the true prevalence is unknown.2,6 There
are no published data on the frequency of
pityriasis capitis, but it has been sug-
gested that it may be a variant of sebor-
rheic dermatitis.2
All studies on the frequency of cuta-
neous conditions are dependent on reli-
able diagnostic criteria. In the case of seb-
orrheic dermatitis and pityriasis capitis,
there are no widely accepted clinical or
other diagnostic criteria that are suffi-
ciently sensitive or specific to the condi-
tions to be confident that what is being de-
scribed is uniquely seborrheic dermatitis
or pityriasis capitis.7
When diagnostic criteria are deter-
mined from patients seen in dermatology
or pediatric clinics, they may be describ-
ing only patients in whom the disease is
biased toward the moderate to severe end
of the spectrum. Features of the very mild

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 forms of disease that may be seen in population-based
studies, but not requiring medical attention, may not be
included in the process leading to diagnostic criteria.
Hence, there may be an underreporting of the true fre-
quency of cutaneous conditions based on diagnostic cri-
teria that are derived from specialist clinics.
The present study aimed to determine the preva-
lence and severity of seborrheic dermatitis and pityria-
sis capitis in a population-based, stratified cross-section
of preschool-aged children examined throughout Victo-
ria, Australia. It also documented the presence of other
common skin conditions seen in preschool-aged chil-
dren including atopic dermatitis, diaper (napkin) der-
matitis, and a variety of birthmarks.8 This report is the
second in a series of reports on the prevalence of the con-
ditions found.
METHODS
A cross-sectional skin survey using a randomly selected clus-
ter sample of child care centers, preschools, and Maternal and
Child Health Centers in both urban and rural communities in
Victoria was undertaken from June 26, 1998, to January 28,
1999. The reference population was Australian children 5 years
and younger. A detailed methodology has been published pre-
viously.8
Parents completed a self-administered questionnaire re-
cording general demographic information on the child and pres-
ent or past personal and family history of skin problems or re-
lated diseases. If the child had any skin condition, information
was recorded regarding treatment and the source of treatment
recommendations. Seborrheic dermatitis and pityriasis capitis
were identified in specific or closed questions within the ques-
tionnaire.
Each child was given a total body examination, with the
underpants (diaper) area being examined only in children
younger than 12 months or at the request of the parent in an
older child. The sites were assessed in the same sequence for
all children.
All data gathered were entered into a database using File-
maker Pro version 4.0 software package for Windows (Claris
Corporation, Santa Clara, Calif). They were analyzed using the
Statistical Package for Social Sciences version 8.0 for Win-
dows (SPSS Inc, Chicago, Ill). Age- and sex-specific preva-
lence rates with 95% confidence intervals (CIs) were calcu-
lated for seborrheic dermatitis and pityriasis capitis. The presence
of either of these conditions reported by the parent or guard-
ian was compared with diagnosis made by the examiner, thus
enabling various indexes of validity to be calculated for the pa-
rental questionnaire. Prevalence estimates were based on data
weighted according to the age and sex of all preschool-age chil-
dren in Victoria.
A diagnostic definition was compiled from what has been
described in standard textbooks of dermatology and any sur-
veys that have been reported. A diagnosis of seborrheic der-
matitis was made if there was erythema with overlying “greasy
scale” in the typical sites of face, trunk, and flexures (usually
in association with scalp involvement) and where the diagno-
sis of atopic dermatitis was considered unlikely, based on the
clinical diagnostic criteria previously reported for atopic der-
matitis.8
Severity of seborrheic dermatitis was divided into mini-
mal (⬍1% of surface area involvement and unlikely to be noted
by those caring for the child and requiring little or no inter-
vention), mild (⬍5% surface area involvement and likely to re-
spond to simple measures, such as emollients), moderate (⬍30%
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of surface area involvement and likely to require medical in-
tervention including the use of mild topical corticosteroids),
and severe (⬎30% surface area involvement, for which man-
agement by a dermatologist and/or hospital admission would
be considered).
A diagnosis of pityriasis capitis was made if there was scal-
ing in the scalp alone in the absence of extrascalp inflamma-
tory skin disease consistent with seborrheic dermatitis. The se-
verity was divided into minimal (fine, powdery white scale,
unlikely to be noted by caregivers and requiring little or no in-
tervention), mild (slightly larger flakes loosely adherent to the
scalp or hair shafts and likely to respond to simple measures
including emollients or gentle manual removal), moderate (thick
flakes or scale, yellowish, and associated with underlying ery-
thema, which would respond to mild topical corticosteroids or
other measures prescribed by a medical practitioner), and se-
vere (very thick scale, closely adherent to the scalp and hair,
involving most of the scalp, associated with erythema, and re-
quiring management by a dermatologist).
RESULTS
POPULATION SAMPLE
Of the original 68 randomly selected centers, 49 partici-
pated in the study. Of the 1634 children in the original
sample, 1116 (68.3%) were examined, 1091 of whom also
had correctly completed parental questionnaires. A com-
parison of the responses in the questionnaire of chil-
dren who were examined with responses in the 139 com-
pleted questionnaires in which the child was not examined
revealed no obvious difference between the groups in
terms of age, sex, and frequency of seborrheic dermati-
tis reported. There were 567 boys (50.8%) and 549 girls
(49.2%), with a mean age of 3 years (range, 11 days to 5
years 11 months).
OBSERVER RELIABILITY
Assessment of surveyor drift as a measure of observer re-
liability showed no significant change in the prevalence
of seborrheic dermatitis or pityriasis capitis in the chil-
dren seen in the first 15 centers compared with the preva-
lence in the children seen in the last 15 centers (␹2 =0.79,
P=.37).
PREVALENCE OF SEBORRHEIC DERMATITIS
AND PITYRIASIS CAPITIS
Seborrheic dermatitis was recorded in 114 of the 1116
children examined (crude point prevalence, 10.2% [95%
CI, 8.4%-12.0%]). The age- and sex-adjusted preva-
lence was 10.0% (95% CI, 8.2%-11.7%). The remainder
of the results are adjusted rates. There was a small, but
not significant, difference in prevalence between boys
(10.4% [95% CI, 7.8%-12.9%]) and girls (9.5% [95% CI,
7.0%-12.0%]). There was a clear age-specific preva-
lence for the disease, occurring in 44.5% (95% CI, 37.1%-
52.0%) of those younger than 12 months, with the high-
est prevalence in children younger than 3 months
(Table 1). There was a substantially decreasing preva-
lence after the age of 1 year.
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 classified as minimal or mild. For seborrheic dermatitis
Table 1. Prevalence of Seborrheic Dermatitis cases, only 27.2% were classified as moderate and 0.9%
and Pityriasis Capitis as severe (Table 2). A breakdown of site by severity
shows that the scalp and face were the sites most com-
Prevalence (95% CI), %
monly affected and that as severity increased, there were
No. of Children Seborrheic an increasing number of sites affected (Table 3).
Examined Dermatitis Pityriasis Capitis For pityriasis capitis cases, 85.8% were classified as
Overall 1116 10.0 (8.2-11.7) 41.7 (38.8-44.6) minimal to mild. The remainder were classified as mod-
Male 567 10.4 (7.8-12.9) 40.2 (36.2-44.3) erate, with no child having severe disease. There was a
Female 549 9.5 (7.0-12.0) 43.2 (39.0-47.3) decreasing prevalence of moderate disease and an in-
Age group creasing prevalence of minimal to mild disease with in-
⬍3 mo 46 71.7 (58.2-85.3) NA
3-5 mo 60 50.0 (37.0-63.0) NA
creasing age (Table 4).
6-8 mo 38 26.3 (11.7-41.0) NA
9-11 mo 38 21.1 (7.5-34.6) NA PARENTAL REPORT OF THE PRESENCE
Total ⬍1 y 182 44.5 (37.1-52.0) 35.7 (28.7-42.7) OF SEBORRHEIC DERMATITIS
1y 176 7.5 (3.6-11.3) 56.3 (48.9-63.7) AND PITYRIASIS CAPITIS
2y 184 7.4 (3.7-11.1) 49.5 (42.2-56.8)
3y 224 0.9 (0-2.2) 34.8 (28.5-41.1)
An analysis of the parental questionnaire revealed a rela-
4y 184 0.5 (0-1.5) 35.3 (28.4-42.3)
5y 166 1.8 (0-3.7) 40.4 (32.8-47.9) tively low awareness of the presence of seborrheic der-
matitis. Although there was a specificity of 82.8% for the
Abbreviations: CI, confidence interval; NA, not applicable. parents reporting an absence of seborrheic dermatitis, the
sensitivity was low (43.0%), as was the positive predic-
tive value (22.6%). The condition was more likely to be
Table 2. Severity of Seborrheic Dermatitis reported by the parents of children having moderate to
severe disease than those having minimal to mild dis-
Severity of Seborrheic Dermatitis, No. (%) ease. There was relatively low awareness by the parents
of pityriasis capitis, despite a question specifically seek-
Minimal Mild Moderate Severe ing the presence of “cradle cap,” a phrase commonly used
Overall 4 (3.5) 78 (68.4) 31 (27.2) 1 (0.9) by the lay community (Table 5).
Male 3 (4.8) 39 (62.9) 19 (30.6) 1 (1.6)
Female 1 (1.9) 39 (75.0) 12 (23.1) 0
TREATMENT OF SEBORRHEIC DERMATITIS
Age group, mo
⬍3 0 23 (69.7) 9 (27.3) 1 (3.0) AND PITYRIASIS CAPITIS
3-5 2 (6.7) 14 (46.7) 14 (46.7) 0
6-8 1 (10.0) 4 (40.0) 5 (50.0) 0 On the questionnaire, 194 parents (34.3%) had correctly
9-11 0 8 (100) 0 0 reported that their child had either seborrheic dermatitis
ⱖ12 1 (3.0) 29 (87.9) 3 (9.1) 0 or cradle cap and provided information on treatment. A
total of 114 products were used by 102 parents (52.8%)
to treat their children’s condition. The products were
There was no consistent trend in frequency by sea- coded according to whether they were available by pre-
son. Although children whose mother was born in Asia scription only, available over the counter without pre-
(5.0% [95% CI, 0.6%-9.3%]) had a lower prevalence than scription, or general products (products that patients
those children whose mother was born in Australia and would not normally be advised to use or products pre-
New Zealand (11.5% [95% CI, 9.6%-13.7%]), the differ- scribed by alternative or allied health practitioners).
ence was not statistically significant (odds ratio [Austra- Medical practitioners provided products by prescription
lia and New Zealand vs Asia], 2.5 [95% CI, 0.99-6.31]). in only 4.4%, with 31.0% obtained over the counter as a
Of the 1116 children, 465 (41.7% [95% CI, 38.8%- medical product and the remaining 64.6% classified as
44.6%]) had pityriasis capitis. There was no difference general products. The products used were classified as
in prevalence between boys and girls, with a male- likely to be efficacious or not. Of the products, 111
female ratio of 0.89 (95% CI, 0.70-1.2). It was most com- could be identified clearly from the questionnaire and 94
mon in children between the ages of 1 and 2 years (Table (84.7%) were classified as efficacious.
1). There was no consistent trend by season. There was In the available information on who parents had
a significantly lower prevalence of pityriasis capitis in chil- sought advice about seborrheic dermatitis, nurses were
dren whose mothers were born in Asia (19.8%) com- the major providers (35.0%). Family and friends
pared with those whose mothers were born in Australia (12.5%), general practitioners (10.0%), and pharmacists
and New Zealand (43.3%; odds ratio [Australia and New (15.0%) were the other common sources of advice. Simi-
Zealand vs Asia], 3.09 [95% CI, 1.86-5.14]). lar sources of advice and frequencies were recorded for
pityriasis capitis.
SEVERITY OF SEBORRHEIC DERMATITIS
AND PITYRIASIS CAPITIS COMMENT

Most children diagnosed on examination with sebor- This study demonstrates that seborrheic dermatitis and
rheic dermatitis and pityriasis capitis had disease that was pityriasis capitis are very common in young children, sup-

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 Table 3. Sites of Seborrheic Dermatitis (Frequency and Severity)

Severity of Seborrheic Dermatitis, No. (%)

% of the Total No. % of Children With
Site of Sites Affected This Site Affected Minimal Mild Moderate Severe
Scalp 33.8 86.0 4 (100) 62 (79.5) 31 (100) 1 (100)
Face 31.4 79.8 3 (75) 59 (75.6) 28 (90.3) 1 (100)
Nappy area 12.8 32.5 3 (75) 20 (25.6) 14 (45.2) 0
Flexures 11.0 28.1 0 21 (26.9) 11 (35.5) 0
Trunk 5.5 14.0 0 4 (5.1) 11 (35.5) 1 (100)
Limbs 4.5 11.4 0 5 (6.4) 8 (25.8) 0
Ears 1.0 2.6 0 2 (2.6) 1 (3.2) 0
Total 100 ... 4 (3.5) 78 (68.4) 31 (27.2) 1 (0.9)

Table 4. Severity of Pityriasis Capitis Table 5. Sensitivity, Specificity, PPV,

and NPV of Parental Questionnaire
Severity of Pityriasis Capitis, No. (%)* for Seborrheic Dermatitis and Pityriasis Capitis

Minimal Mild Moderate Dermatologists’ Diagnosis

Overall 120 (25.8) 279 (60.0) 66 (14.2)
Male 57 (25.0) 141 (61.8) 30 (13.2) Yes No
Female 63 (26.6) 138 (58.2) 36 (15.2) Seborrheic Dermatitis
Age group, y Parental report
⬍1 6 (9.2) 40 (61.5) 19 (29.2) Yes (n = 217) 49 168
1 19 (19.2) 66 (66.7) 14 (14.1) No (n = 874) 65 809
2 18 (19.8) 60 (65.9) 13 (14.3) Total (n = 1091) 114 977
3 25 (32.1) 42 (53.8) 11 (14.1) Sensitivity/specificity, % 43.0/82.8
4 24 (36.9) 38 (58.5) 3 (4.6) PPV/NPV, % 22.6/92.6
5 28 (41.8) 33 (49.3) 6 (9.0)
Pityriasis Capitis
Parental report
*No child was classified as having severe disease. Yes (n = 219) 145 74
No (n = 872) 307 565
porting and quantifying impressions stated in com- Total (n = 1091) 452 639
monly used textbooks of dermatology. The major prob- Sensitivity/specificity, % 32.1/88.4
lem with these conditions is diagnostic definition. In this PPV/NPV, % 66.2/64.8
study, we have been liberal and therefore inclusive rather
Abbreviations: PPV, positive predictive value; NPV, negative predictive
than exclusive in recording the presence of scaling, which value.
has led to the very high frequency of pityriasis capitis. A
prevalence of around 50% in children up to the age of 3
years suggests that the condition might be considered nor- titioners who write the literature on common skin dis-
mal for the community. A large proportion of children eases and teach nursing staff and other allied health pro-
with these changes were classified as having minimal to fessionals what they believe is the disease that comes under
mild conditions and were not reported by their parents these diagnoses.
to have any abnormality. Thus, it is unlikely that these Nevertheless, this study has detected changes, a sub-
children would have been taken to a medical practi- stantial proportion of which were inflammatory skin dis-
tioner and diagnosed as having pityriasis capitis. If only ease, in a very large number of preschool-age children in
those who had moderate or severe disease (ie, those who Victoria. Many parents had been sufficiently concerned to
would benefit from advice from a medical practitioner) seek advice and use products in an attempt to either treat
were included, the overall prevalence for pityriasis capi- the condition or prevent it from recurring. If this is the
tis would become 14.2%, with the highest prevalence in case, then it represents a public health problem, much of
those younger than 1 year (29.2%) and decreasing in fre- which could be easily prevented by avoidance of com-
quency with increasing age. These figures are probably mon irritants such as soap and the regular use of emol-
more consistent with what has been diagnosed as pity- lients such as simple bath oils or other moisturizers.
riasis capitis in medical textbooks. All newborns in Victoria are registered by the local
The same comments apply to the frequency of seb- Maternal and Child Health Center and are seen at regu-
orrheic dermatitis. A prevalence of 71.7% in children lar intervals for the first 3 years of life. The large propor-
younger than 3 months could be argued to be almost a tion of parents reporting Maternal and Child Health nurses
normal or physiological change. It is likely that only the as their source of advice when they sought it clearly shows
30.3% of cases classified as moderate or severe disease that they are viewed as their professional advisors. Our
would be incorporated into a classification of sebor- data point to these nurses as the target group for an edu-
rheic dermatitis based on those who require treatment cation program on common skin problems for new moth-
by a medical practitioner. Generally, it is medical prac- ers and their children.

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 Accepted for publication June 18, 2002.
This work was supported by grants from the Austra-
lian Dermatology Research and Education Foundation, Syd-
ney, Australia; and the F. and E. Bauer Foundation, Mel-
bourne, Australia.
We would like to thank the Victorian Department of
Human Services, child care center staff, Maternal and
Child Health nurses, and especially all the children and
parents who participated in the survey. We also acknowl-
edge Nicole Jenner, BMRA, GradCertHlthSc (Clinical Data
Management), who helped in data entry and analysis of
the study; Marlene Rennie, for editing assistance; and Jan
Campbell, MA, for her constructive comments on the final
manuscript.
Corresponding author: Peter Foley, MD, FACD, De-
partment of Medicine (Dermatology), The University of Mel-
bourne, St Vincent’s Hospital Melbourne, PO Box 2900,
Fitzroy, Victoria 3065, Australia (e-mail: foleyp
@svhm.org.au).
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Textbook of Dermatology. 6th ed. Oxford, England: Blackwell Science Ltd; 1998:
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3. Johnson M-LT, Roberts J. Prevalence of Dermatological Disease Among Per-
sons 1-74 Years of Age: United States. Hyattsville, Md: National Center for Health
Statistics; 1977:1-7. Advance Data From Vital and Health Statistics. No. 4.
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matology clinic. Pediatr Dermatol. 1983;1:157-164.
5. Goh C, Akarapanth R. Epidemiology of skin disease among children in a referral
skin clinic in Singapore. Pediatr Dermatol. 1994;11:125-128.
6. Plewig G, Jansen T. Seborrheic dermatitis. In: Freedberg I, Eisen A, Wolff K, et
al, eds. Fitzpatrick’s Dermatology in General Medicine. 5th ed. New York, NY:
McGraw-Hill Co; 1999:1482-1489.
7. Yates V, Kerr R, MacKie R. Early diagnosis of infantile seborrhoeic dermatitis
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News and Notes

A course on humanitarian assistance for dermatologists, intended to pre-

pare dermatologists for participation in humanitarian assistance projects
under austere circumstances, will be offered in Bethesda, Md, from June 2 through
June 6, 2003. The primary audience is federal dermatologists and residents, but
the course is open to civilian dermatologists and residents with interest or ex-
perience in humanitarian assistance. The course is ideal for people who might
volunteer to work with organizations that provide medical or humanitarian as-
sistance and disaster relief. The course is offered under the auspices of the De-
partment of Dermatology, Uniformed Services University of the Health Sci-
ences, and the Center for Disaster and Humanitarian Assistance Medicine. Up
to 30 hours of AAD/AMA Level I CME will be awarded. The course has a lim-
ited enrollment. For more information, contact the course director, Scott A.
Norton, MD, MPH, Dermatology Service, Walter Reed Army Medical Center,
Washington, DC 20307; phone: (202) 782-9484; fax: (202) 782-9118 (e-mail:
scott.norton@na.amedd.army.mil).

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