Dandruff

The Skin Center

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Dandruff

 

·    Dandruff Overview

 

Dandruff Overview

Dandruff is a very common skin condition that affects the scalp, ears, eyebrows, sides of the nose, beard, and less commonly the central (often hair bearing) part of the chest. Other names for dandruff are seborrheic dermatitis or seborrhea.

 

There are many variations of dandruff and most people are not aware that dandruff frequently affects non-scalp areas like the face and ears. Dandruff is one of the most common types of skin conditions that nearly all people have at one point in their lives. It is important to keep in mind that dandruff is seen in all ages from babies to the elderly. In infancy, scalp dandruff is commonly known as “cradle cap”. In the teen years it has been called “druff” for short. Dandruff can affect any hair bearing area or an area with even very small hair follicles. Interestingly, many furry pets like dogs, cats, rabbits, hamsters also have dandruff.  Some people are simply more prone to dandruff and others have up and down courses with periodic clearing and periodic flares.

 

The exact cause of dandruff is unknown. Increased oil production, oily skin, increased skin secretions, and possible increased numbers of normal skin yeasts may be triggering factors.  Dandruff  is not a fungal infection and is not the same as  scalp “ringworm” which is called tinea capitis. Dandruff can also be triggered by poor hygiene and  infrequent shampooing. Although mild dandruff  is a very common and temporary condition in just about everyone at sometime, severe dandruff is generally more common in people with  chronic illnesses or a compromised immune system like in advanced HIV/ AIDS.

 

Dandruff typically looks like dry, fine flaky skin on the scalp with areas of pink or red, inflamed skin. Many individuals have no scalp symptoms but simply complain of white flakes on their shoulders, particularly noticeable on dark clothing.  More advances cases may cause intense itching, burning, and unstoppable scratching.

 

Dandruff is a very common condition, and it affects all races and ages, including young infants. Nearly everyone may have dandruff at one point in their life.

 

Dandruff tends to be a chronic or recurrent disorder with periodic ups and downs. Although it is not curable, it is generally quite easily controlled with proper skin and hair hygiene.  In babies, cradle cap usually clears after a few months. It may recur later in life as typical dandruff. For some, dandruff may worsen with time. Although it may occur just for a short period, dandruff tends to recur throughout life or last a lifetime.

 

Severe dandruff may be a very difficult and frustrating condition.  An ongoing combination treatment of multiple shampoos, washes, and creams and lotions may be required to treat resistant cases. Overall, dandruff treatments are very safe and effective.  Best shampoo choices include antifungal shampoos like Nizoral.

 

 

Dandruff Causes

 

The exact cause of dandruff is unknown. Possible causes and associations include increased oil production, oily skin, increased skin secretions, and increased numbers of normal skin yeasts. Bacteria have not been found to cause dandruff.

 

Dandruff may also be triggered by poor hygiene, and infrequent shampooing and washing. The immune system may play a part in dandruff. Although mild dandruff is a very common condition in many people with a normal immune system, severe dandruff is generally more common in people with  chronic illnesses or a compromised immune system like advanced HIV/AIDS and Parkinson’s  Disease.

 

  • ·    Common triggers of dandruff include the following:

o   Increased oil production

o   Oily skin

o   Oily scalp

o   Sweating

o   Poor hygiene

o   Weather (hot and humid or cold and dry)

o   Infrequent washing or shampooing

o   Yeast or fungus

o   Poor immune system

o   Chronic illness

o   Emotional or mental stress

  • ·    Risk factors for dandruff include the following:

o   People with extreme or severe cases of dandruff usually also have other chronic health conditions

o   Dandruff  probably has a small hereditary component making it more common in  other family members.

o   Dandruff is not contagious.

 

 

Dandruff Symptoms

 

Medical professionals and skin specialists called Dermatologists commonly refer to dandruff as seborrhea or seborrheic dermatitis.

  • ·    White flakes on shoulders of dark clothing
  • ·    Itchy scalp
  • ·    Dry facial skin
  • ·    Recurrent ear “eczema”
  • ·    Face rash by eyebrows, nose, and ears
  • ·    Oily scalp and face skin with dry flakes
  • ·    Eyebrow dandruff
  • ·    Beard dandruff
  • ·    Chest rash with dry flakes and red spots

 

One of the most common and often the first symptom of dandruff can be white flakes on your dark clothes. Scalp itching may be another common first symptom. In some, the initial noticeable symptom is simply dry facial skin without any other rashes. Patients may see their physician complaining of dry skin that fails to respond to daily lotions and creams. Often they have used every lotion and potion possible from the drugstore or more expensive department stores. Frequently this is caused by undiagnosed scalp dandruff which is causing problems “downstream” on the face.

 

Dandruff can be located anywhere on the body that has any type of hair follicles. It is most typically found on the scalp, ears, face, and mid chest. Seborrhea is not seen on the palms and soles where there are no hair follicles.

 

When to Seek Medical Care

 

If dandruff is worsening (spreading, causing hair loss, increasing redness, painful, infected) despite proper skin care and hair hygiene, call your heath care provider or dermatologist for an office appointment.

 

Proper home care includes daily shampooing with over the counter cleansers like Nizoral Shampoo, Selsun Blue, or Head and Shoulders and topical applications of  mild cortisone creams like  Hydrocortisone 1% or Cortaid over 1-2 weeks. Getting rid of dandruff permanently is not possible.

 

If you are so uncomfortable that your social, sleep, work, or other daily activities are disrupted, you need a more effective treatment and should see your health care provider.

 

If you are having a great deal of hair loss you should seek care from your dermatologist.

 

Dandruff is not a medical emergency and should not be handled in a hospital emergency department. You may call your pediatrician, family physician, internist, or dermatologist for a medical consultation.

 

Exams and Tests

 

Dandruff is generally fairly easy to diagnose. A medical professional can usually identify dandruff by looking at the rash and asking questions about how it appeared.

 

In rare instances, highly atypical cases may require more exams and tests including skin scrapings, microscopic evaluation, blood tests, and skin biopsies. Your provider may scrape some scales off the rash and look at them under the microscope to make sure the rash is not caused by a fungus. A very small piece of skin may be taken for microscopic exam to exclude other causes like psoriasis, lupus, and skin diseases. Other types of rashes and skin infection also may be ruled out.

 

Other possible diagnosis:

  • ·    Psoriasis
  • ·    Rosacea
  • ·    Tinea Capitis ( fungal scalp and hair infection)
  • ·    Contact dermatitis
  • ·    Eczema
  • ·    “Ringworm”
  • ·    Xerosis
  • ·    Allergic dermatitis
  • ·    Sebopsoriasis
  • ·    Seborosacea
  • ·    Perioral dermatitis
  • ·    Acne
  • ·    Pruritus
  • ·    Lupus
  • ·    Other autoimmune disorders
  • ·    Photodermatitis

 

The four key features of dandruff are:

  • ·    Dry, white skin flakes on any hair bearing parts of the body
  • ·    Dry skin by eyebrows, ears, and nose   
  • ·  White flakes on clothes
  • ·    Itchy or dry scalp

 

Dandruff Treatment

 

Self-Care at Home

 

Proper home care often includes daily scalp shampooing with over the counter cleansers like Nizoral Shampoo, Selsun Blue, or Head and Shoulders shampoos. All affected areas including the scalp, ears, face, and chest should also be washed with the therapeutic shampoo.

 

Best Shampoo for heavy adult dandruff:

  • ·        Nizoral Shampoo (ketoconazole)
  • ·        Head and Shoulders Shampoo
  • ·        Selsun Blue Shampoo (selenium sulfide)

 

People who shampoo less often like once or twice a week are usually much more prone to dandruff. Simply increasing your shampooing frequency often helps clear mild dandruff. Getting rid of dandruff permanently is not possible.

 

Skin inflammation may be treated with topical applications of mild over the counter cortisone creams or lotions like hydrocortisone 1% or Cortaid over 2-4 weeks. Apply the cortisone cream sparingly 1-3 times a day to the affected skin areas to help decrease inflammation. Home remedies include:

  • ·        Hydrocortisone 1% cream or lotion
  • ·        Cortaid cream

 

For face and ear dandruff, washing the areas with a medicated shampoo like Nizoral may be very helpful. Avoid oily or heavily oiled hair and skin products. Avoid occlusive hats, caps, head wraps, or helmets.

 

Eyelid dandruff may be treated with gentle daily applications of Johnson and Johnson Baby Shampoo. A cotton tip applicator (Q- tip) may be used to clean the lash margin while avoiding getting the shampoo directly into the eyes.

 

“Cradle Cap” in babies may be treated with more frequent scalp washing using Johnson and Johnson Baby Shampoo. For really thick stuck on scalp flakes, a small children’s soft toothbrush dipped in warm olive oil can be used to very gently massage away some of the flakes daily or every other day. Care should be taken not to scrub or aggressively rub the fragile scalp skin. Your pediatrician is very important in the guidance of care for infants.

 

For those who desire more natural or holistic type of treatments, white vinegar (natural cleansing properties) may be used to clean the scalp and facial skin. While this may not take the place of other more effective therapies, it can be helpful to use a dilute (1 part white vinegar to 3 or 4 parts water) once a day or 2-3 times a week to clean the scalp.

 

Since dandruff tends to be chronic, you should not expect an overnight cure or quick response. Dandruff control may require long-term skin and hair care for best results.

 

Medical Treatment

 

Once your health care provider has confirmed you have dandruff (seborrheic dermatitis), the bread and butter of your treatment includes antifungal shampoos, antibacterial cleansers, and anti-inflammatory creams and lotions. It is very important to keep in mind that often the most effective dermatologic treatments are combination treatments using several different medicated ingredients used at the same time.

 

Prescription-strength shampoos and steroid cream medication are the usual treatments. More frequent shampooing and cleansing will usually be recommended.

 

For severe cases not responding to a combination of ultra high-potency steroid creams, foams, sprays or lotions, alternate treatments may be tried. A dermatologist may be very helpful for resistant cases that have not cleared with standard prescriptions.

 

Rare severe cases may require short-term treatment with oral steroids like prednisone and/or oral antifungal pills. Oral pills are not the mainstay of dandruff treatment and should not be routinely used.

 

Sample escalating (step-up) treatment of adult dandruff by dermatologist:

 

Skin Care routine for Mild Dandruff:

  • ·        Wash scalp with Nizoral or Loprox Shampoo daily or every other day
  • ·        May use hair conditioner on hair as needed (avoid applying to scalp)
  • ·        Need more frequent daily shampooing when symptoms are more severe

 

Skin Care routine for Moderate Dandruff:

  • ·        Wash scalp with Nizoral or Loprox Shampoo daily
  • ·        May use hair conditioner on hair as needed ( avoid applying to scalp)
  • ·        Need more frequent daily shampooing when symptoms are more severe
  • ·        Rub in fluocinonide or clobetasol solution 1-2 times a day into scalp for itchy skin

 

Skin Care routine for Severe Dandruff:

  • ·        1st wash scalp with a tar shampoo like Neutrogena TGel or DHS Tar
  • ·        Rinse scalp
  • ·        2nd wash scalp with salicylic acid shampoo like DHS Sal or Neutrogena TSal
  • ·        Rinse scalp
  • ·        3rd Wash scalp with Nizoral or Loprox Shampoo daily and leave in for 2-5 minutes
  • ·        Rinse scalp
  • ·        May use hair conditioner on hair as needed ( avoid applying to scalp)
  • ·        Rub in Olux foam or clobetasol solution 1-2 times into scalp for itchy, inflamed  skin  areas
  • ·        Use weekly or biweekly special nourishing bedtime treatment with Dermasmoothe under shower cap. Rinse off in the morning.
  • ·        As dandruff improves, step back to every other day treatments or rescale to the moderate  or mild dandruff recipe above

 

Medications

  • ·    Antifungal shampoos – Prescription strength shampoos help decrease the yeast counts on your skin.

-     Nizoral Shampoo

-         Loprox Shampoo

  • ·    Antibacterial cleaners- Prescription strength washes like sulfacetamide help decrease the bacterial counts on your skin.

-         Rosanil

-         Clenia

-         benzoyl peroxide cleansers

  • ·    Cortisone shampoos – Prescription strength steroid shampoos in rinse off products help decrease the inflammation and decrease itching.

-         Capex Shampoo

-         Clobex Shampoo

  • ·    Corticosteroids – Prescription strength cortisone preparations as rub in and leave on products help decrease the inflammation and control itching. These vary in strength, the strongest of which is about 1000 times the strength of over the counter hydrocortisone!

 

Topical cortisones are safe when used effectively under a physician’s care and guidance. As there are many known, possible long term side effects of all steroids, they should be used sparingly and only where needed. Many cortisone preparations are available including ointments (more greasy, clear, petroleum based) creams (thick, white and lubricating), lotions (light, flowing liquid), solutions (clear watery liquid, often alcohol based), sprays (clear liquid in propellant) and foams (light, airy mousse).

-         Olux foam

-         Luxiq foam

-         clobetasol solution

-         Synalar solution (fluocinonide)

-         Clobex Spray

-         Clobex Lotion

-         Kenalog Spray ( triamcinolone)

 

Next Steps

 

Follow-up

  • ·    Use all your shampoos and medications as prescribed and expect gradual improvement.
  • ·    Keep in mind that many people have dandruff and most individuals do require long-term changes in skin care and a commitment to proper hair and skin hygiene.
  • ·    If the prescription medications are not controlling the Dandruff or your prescription medications are running out, make an appointment with your health care provider.
  • ·    You should see your medical provider once or twice a year for this condition. If your condition is spreading or has changed substantially, you should also see your medical provider to make sure there are no new conditions or diagnosis.

 

Prevention

 

Practicing good skin and hair hygiene may help prevent flares of dandruff. More regular or frequent shampooing is important during flares.

 

See Self-care at home for other ideas on preventing Dandruff flares.

 

Outlook

 

The outlook for dandruff is good. Although dandruff is not curable, it is controllable. While the exact cause remains unknown, typically dandruff is easy to control with medicated shampoos and topical cortisone products. Dandruff may spontaneously clear even without treatment.  Babies frequently completely outgrow their dandruff or “cradle cap”. Since most commonly dandruff tends to be chronic, this means you may have occasional flares and remissions of the symptoms, more at times of poor health or stress.

Synonyms and Keywords

Dandruff, seborrhea, seborrheic dermatitis, cradle cap, pityriasis amiantacea, tinea amiantacea, scalp dermatitis, sebopsoriasis, scalp psoriasis, flaky scalp, dry scalp, eyebrow dandruff, face dandruff, ear dandruff, ear dermatitis, itchy scalp, pruritic scalp, scalp pruritus, dry face, dry ears, eyelid dandruff, dry eyelids, walking dandruff, oily dandruff, dry dandruff,

Authors and Editors

Author: Nili N. Alai, MD, FAAD, The Skin Center at Laguna, Assistant Clinical Professor of Dermatology University of California, Irvine

 


 

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