What is dandruff

Dandruff, also called seborrheic dermatitis of the scalp or pityriasis capitis, is an uninflamed form of seborrhoeic dermatitis on the scalp. Dandruff is a common scalp (the skin covering your head) condition in which small pieces of dry skin flake off of your scalp. If you have dark hair or you’re wearing dark colors, you may notice the flakes in your hair or on your shoulders. Dandruff involves overproduction and flaking of skin cells, which can cause itchy skin on your scalp and sometimes behind your ears, on your face, and on your neck. Dandruff presents as diffuse bran-like scaly patches within hair-bearing areas of the scalp without underlying redness. Dandruff may be asymptomatic (no symptom) or mildly itchy.

Figure 2. Dandruff

Figure 3. Seborrheic dermatitis scalp

What causes dandruff?

The cause of dandruff is thought to involve many factors and is still being researched. Dandruff can develop due to multiple reasons, including some medical conditions, your hair care habits, or oily skin.

Dandruff may be caused by:

• Irritated, oily skin
• Dry skin
• A yeastlike fungus (Malassezia furfur also called Pityrosporum ovale) that feeds on oils on the scalps of most adults
• Sensitivity to hair care products (contact dermatitis)
• Other skin conditions, such as psoriasis and eczema

A harmless yeast, Malassezia also called Pityrosporum ovale, is present on normal skin but in seborrheic dermatitis is found in higher amounts. Current thinking is that abnormalities in the skin barrier and increased sensitivity to oleic acid produced by the Malassezia yeast result in inflammation causing dandruff. The Malassezia yeast that is present on the skin is not the same as the Candida yeasts that cause thrush or those that are present in foods.

Risk factors for getting dandruff

Almost anyone can have dandruff, but certain factors can make you more susceptible:

• Age. Dandruff usually begins in young adulthood and continues through middle age. That doesn’t mean older adults don’t get dandruff. For some people, the problem can be lifelong.
• Being male. Dandruff is more prevalent in males than in females.
• Certain illnesses. Parkinson’s disease and other diseases that affect the nervous system also seem to increase risk of dandruff. So does having HIV or a weakened immune system.

Factors that might increase your risk of dandruff include family history, stress, fatigue, use of alcohol-containing lotions, skin disorders, obesity, HIV, and certain neurologic conditions. In patients with HIV and AIDS, 35% of those with early HIV infection have dandruff, and 85% in patients with AIDS ⁷. Risk factors for dandruff include immunodeficiency, neurological diseases including Alzheimer’s disease and Parkinson disease, increased sebaceous gland activity, and exposures to drug treatment, including lithium, immunosuppressants, and dopamine antagonists ⁸. Flares of dandruff can be triggered by tiredness, stress and cold, dry weather. However, in the majority of people, dandruff is not usually linked to any underlying illness.

Dandruff signs and symptoms

Dandruff signs and symptoms may include:

• Itchy scalp that sheds white oily skin flakes.
• Skin flakes on your scalp, hair, hairline, forehead, eyebrows, in between the eyebrows, and the area of the eyelid between the eye and the eyelashes, beard or mustache, and shoulders.
• Scaly, crusty scalp in infants with cradle cap
• In lighter skin colors, affected areas may appear pink or red. In darker skin colors, the redness may be subtle; affected areas may appear purplish or darker brown, but the affected areas look lighter in color (hypopigmented).

The signs and symptoms of dandruff may be more severe if you’re stressed, and they tend to flare in cold, dry seasons.

Dandruff diagnosis

A doctor can often diagnose dandruff simply by looking at your hair and scalp.

Dandruff differential diagnosis

Other problems that can affect your scalp include:

• Scalp ringworm, a fungal infection that causes itchy, red patches on your head. It can also leave bald spots. It usually affects children.
• Scalp psoriasis, which causes itchy or sore patches of thick, red skin with silvery scales. About half of the people with psoriasis have it on their scalp.

Dandruff treatment

The itching and flaking of dandruff can almost always be controlled. Most cases of dandruff are easy to control with nonprescription self-care treatments at home. These include:

• For mild dandruff, first try regular cleansing with a gentle shampoo to reduce oil and skin cell buildup. Frequent shampooing or a longer lather time with shampoo. If regular daily shampoo fails, try a medicated dandruff shampoo. There are several types on the market, and one may work better for one individual than another. Shampoos containing ketoconazole (Nizoral), selenium sulfide (Selsun Blue), 2% pyrithione zinc (Head & Shoulders), salicylic acid (Neutrogena T/Sal), or tar-based (Neutrogena T/Gel) compounds may be helpful. Consider occasionally rotating shampoos because how well a product works (its efficacy) can change with time. Some people can tolerate using a medicated shampoo two to three times a week, with regular shampooing on other days if needed. People with drier hair would benefit from less frequent shampooing and a moisturizing conditioner for the hair or scalp.
• For long-term control, your doctor may prescribe antifungal shampoos that contain ciclopirax (Loprox) or ketoconazole (Nizoral). These shampoos are used from daily to two or three times a week for several weeks until the dandruff has cleared, then once every week to two weeks to prevent flare-ups. Your doctor will give you specific directions for use.
• If your scalp is covered with dandruff is widespread with dense scale, the scale may be removed by applying warm mineral oil or olive oil to the scalp and washing several hours later with a detergent, such as a dishwashing liquid or a tar-based shampoo.
• Some over-the-counter creams will help if the medicated shampoo is not working well enough. These can be added to the shampoo until there is improvement and then can be discontinued; these creams can be used again temporarily as needed and include:
  • Creams that reduce the Malassezia yeast (Pityrosporum ovale) (clotrimazole [Lotrimin], miconazole [Monistat]).
  • Hydrocortisone cream (e.g, Cortaid), which may work well at first but may be less helpful if used for a long time.
• For moderate to severe cases, your doctor may prescribe a shampoo containing betamethasone valerate (Luxiq), clobetasol (Clobex), fluocinolone (Capex) or fluocinolone solution (Synalar). Shampoo your hair as directed. Some products are used daily, others are used twice daily for two weeks then two times a week.
• Managing eyelid inflammation (blepharitis) by gentle cleansing of the skin around the eyelashes with a cotton swab and baby shampoo (eg, Johnson’s Baby Shampoo).

In the case of severe or stubborn dandruff, your doctor may prescribe:

• Corticosteroid creams, lotions, or solutions.
• Sulfur or sulfacetamide products, such as a wash, cream, or lotion.
• Ketoconazole shampoo or cream.
• Tacrolimus (Protopic) ointment or pimecrolimus (Elidel) cream.

Dandruff shampoo

Dandruff shampoos are classified according to the medication they contain. Some are available in stronger formulations by prescription.

Look for a shampoo with one of the following ingredients:

• Zinc pyrithione. Zinc pyrithione is an antibacterial and antifungal chemical compound used to treat dandruff, seborrheic dermatitis and and tinea versicolor. Zinc pyrithione increases cellular copper levels and damages iron-sulfur clusters in proteins that are essential for fungal metabolism and growth. Zinc pyrithione shampoos (DermaZinc, Head & Shoulders, others) work by killing bacteria, fungus, and microorganisms that can cause an itchy, flaky scalp.
• Salicylic acid. Salicylic acid belongs to a group of medicines known as keratolytics. Salicylic acid works by softening keratin, a protein that forms part of the skin structure. This helps to loosen dry scaly skin making it easier to remove. Salicylic acid breaks down the outer layer of the skin to treat dry, scaly, or thickened skin conditions. Salicylic acid is used in the treatment of scaly skin diseases where the skin has become thickened, scaly and flaky. Shampoos containing salicylic acid (Jason Dandruff Relief Treatment Shampoo, Baker P&S, others) help eliminate scaling.
  • How to use salicylic acid shampoos:
    • It is very important that you use preparations strictly as directed on the label. Do not use more of it, do not use it more often, and do not use it for a longer time than recommended. Failing to follow instructions may lead to increased absorption through the skin and salicylic acid poisoning.
    • Avoid contact with eyes and other mucous membranes, such as the mouth, inside of the nose, and genitals. Accidental application to areas should be flushed immediately with water for 15 minutes.
    • Do not use on irritated skin or on any area that is infected or reddened.
    • Protect areas surrounding the affected area by applying petroleum jelly around the periphery of the area to be treated.
    • Unless your hands are being treated, wash them immediately after applying this medicine.
• Selenium sulfide. Selenium sulfide is an anti-infective medication that treats fungal or yeast infections of the skin, including dandruff, seborrheic dermatitis, and tinea versicolor. Selenium sulfide shampoos (Head & Shoulders Intensive, Selsun Blue, others). Selenium sulfide treats the excess shedding and irritation by eliminating excess scalp fungus and controlling the rate of shedding of dead skin cells. Use selenium sulfide shampoos as directed and rinse well after shampooing, as they can discolor the hair and scalp. Precautions: selenium sulfide can be used safely on the scalp in pregnant women. It should not be used on the body to treat skin infections if you are pregnant as selenium sulfide may be absorbed through the mother’s skin.
  • Selenium sulfide shampoos for dandruff:
    1. Wet hair and scalp with lukewarm water
    2. Apply enough selenium sulfide shampoo to the scalp to work up a lather
    3. Allow lather to remain on scalp for 2-3 minutes before rinsing off
    4. Repeat with a second wash then rinse well
    5. Wash hands well and clean under nails to remove any shampoo
    6. Use 1% or 2.5% selenium sulfide shampoo twice a week for the first 2 weeks, then once weekly for 2, 3 or 4 weeks, and then only when necessary
• Ketoconazole. Ketoconazole is an antifungal medication. Ketoconazole treats fungal or yeast infections in your skin. Ketoconazole binds to the fungal p450 enzymes and stops the cells making ergosterol, the main component of the cell wall. Ketoconazole shampoos (Nizoral Anti-Dandruff). Ketoconazole shampoo is intended to kill dandruff-causing fungi that live on your scalp. You can use this medicated shampoo as you would use a regular shampoo by massaging it into your skin. Follow the label for directions on how long you should let the product set before rinsing it off.
• Ciclopirox. Ciclopirox is an antifungal medication. Ciclopirox works by stopping the growth of nail fungus. Ciclopirox shampoo (Loprox) is used to seborrheic dermatitis and dandruff. Ciclopirox shampoo is used daily to two or three times a week for several weeks until the dandruff has cleared, then once every week to two weeks to prevent flare-ups. Your doctor will give you specific directions for use.
• Coal tar. Coal tar or crude coal tar is obtained by the destructive distillation of bituminous coal at very high temperatures. It is believed that over 10,000 different compounds make up coal tar, but only 400 or so have been identified. Coal tar is still used to treat a variety of skin disorders, particularly conditions where the skin is flaky and scaly. Exactly how coal tar works to treat these conditions is not completely understood. It appears to have antimicrobial, antipruritic (reduce itching) and keratoplastic (normalize keratin growth in the skin and reduce scaling) effects. Coal tar-based shampoos (Neutrogena T/Gel, Scalp 18 Coal Tar Shampoo, others) slow how quickly skin cells on your scalp die and flake off. If you have light-colored hair, this type of shampoo may cause discoloration. It can also make the scalp more sensitive to sunlight.
• Fluocinolone. Fluocinolone is in a class of medications called corticosteroids. Fluocinolone works by activating natural substances in your skin to reduce swelling, redness, and itching. Fluocinolone shampoos (Capex, Derma-Smoothe/FS, others). These shampoos contain a corticosteroid to help control itching, flaking and irritation.

If one type of shampoo works for a time and then seems to lose its effectiveness, try alternating between two types of dandruff shampoos. Once your dandruff is under control, try using the medicated shampoo less frequently for maintenance and prevention.

Read and follow the directions on each bottle of shampoo you try. Some products need to be left on for a few minutes, while others need to be rinsed off quickly.

If you’ve used medicated shampoo regularly for several weeks and still have dandruff, talk to your doctor or dermatologist. You may need a prescription-strength shampoo or a steroid lotion.

For moderate to severe cases, your doctor may prescribe a shampoo containing betamethasone valerate (Luxiq), clobetasol (Clobex), fluocinolone (Capex) or fluocinolone solution (Synalar). Ask your doctor about what side effects to watch for while using these shampoos.

In the case of severe or stubborn dandruff, your doctor may prescribe:

• Corticosteroid creams, lotions, or solutions.
• Sulfur or sulfacetamide products, such as a wash, cream, or lotion.
• Ketoconazole shampoo or cream.
• Tacrolimus (Protopic) ointment or pimecrolimus (Elidel) cream.

Ask your doctor about the side effects of these medications and what to watch for. Follow your doctor’s instructions about how to take these medications. You and your doctor will work closely together to select products and develop a treatment plan that will be most helpful to treat your unique case of dandruff.

See a doctor who specializes in skin conditions (dermatologist) if your condition doesn’t improve with regular use of dandruff shampoo, creams, lotions or ointments.

Dandruff prognosis

Dandruff is usually a chronic condition, so it will tend to come back. Use an antidandruff shampoo once or a twice a week to help control it.

For most people, dandruff does not require medical attention. If your dandruff doesn’t go away after following these tips, or if you develop severe dandruff, see a board-certified dermatologist. Your dermatologist may prescribe stronger dandruff shampoo or medication. Your dermatologist also knows whether your dandruff is a sign of a medical condition, such as seborrheic dermatitis, psoriasis, fungal infections of the scalp, or eczema.

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