Dandruff is a term that generally applies to a constellation of flaking and itching of the scalp along with possible dryness and greasiness. The irony for many of my patients is the presence of both oiliness and dryness simultaneously. This is often referred to as “greasy scales”. Many drugstore products can manage this condition. Read more...
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What is dandruff?
Dandruff is a term that generally applies to a constellation of flaking and itching of the scalp along with possible dryness and greasiness. The irony for many of my patients is the presence of both oiliness and dryness simultaneously. This is often referred to as “greasy scales”. The term “dandruff” itself is not a medical term. Dandruff refers to an experience of a dry scalp with flaking, greasiness, and possible itching. The triggers for dryness of the scalp along with flaky skin, greasy or oily hair, and possible itching can include seborrheic dermatitis, psoriasis, irritant contact dermatitis, xerosis, autoimmune and inflammatory conditions such as lichen planopilaris, and even terra firma or dermatitis neglecta from an accumulation of residues, oils, and keratin from infrequent hair washing. To tell the difference between these triggers, we have to take into consideration patterns, location of scaling, type of scaling, personal care habits, product use, seasonality, overall health, and the environment.
What is the most common cause of dandruff?
This constellation of symptoms is most commonly associated with a medical diagnosis of seborrheic dermatitis. There can also be some overlap, in some cases, with psoriasis lending to the term sebopsoriasis. Seborrhea is not completely understood but is thought to be the result of inflammation triggered by the presence of Malassezia yeast (previously referred to as Pityrosporum).
What is the best way to manage seasonal dandruff, seborrhea, or psoriasis?
Dandruff can have a significant seasonal tendency for many people. I advise my patients that the most important first step they can take is to anticipate it. We know that dandruff will generally flare in the Fall and/or Spring. It appears to coincide with temperature transitions. Knowing this, plan to start preventative approaches 4 weeks in advance. Dandruff shampoos cannot always effectively treat dandruff once it flares but are actually pretty good at preventing it. Start thinking dandruff shampoos as early as February and August to be one step ahead. If there is breakthrough flaking, itching, and dryness after taking preventative measures, there are a variety of over-the-counter options to consider before seeking prescription remedies.
Which over-the-counter treatments work best for dandruff?
When looking at the wide range of products to determine how to get rid of dandruff, it helps to learn how each works. Dandruff can be managed with a number of topical options found over the counter. Remember that there are two main components to dandruff to address : (1) Itch (2) Flaking There are some ingredients that address one or the other or both. Below are the most common ingredients to consider. Remember that dandruff is truly an inflammatory process that leads to itching and flaking. If it does not respond to these over-the-counter ingredients it is worth seeing your dermatologist to confirm the diagnosis as dandruff (seborrhea) and not psoriasis.
Coconut oil ✔️Anti-itch ✔️Anti-flake
Coconut oil is gaining a lot of attention in skincare products. It is a proven emollient that can effectively hydrate the skin. It also has antimicrobial and anti-inflammatory properties. These can be beneficial for dry flaky scalps to help hydrate and reduce the tendency towards scaling or flaking.
Apple cider vinegar (ACV)
I don’t think a day goes by where a patient doesn’t tell me that they used apple cider vinegar to treat something! ACV has anti-yeast properties and has been used to treat diaper rash. Since seborrheic dermatitis is thought to be related to yeast that overgrows on our skin. It can often be added to scalp exfoliators to help address the underlying yeast that triggers inflammation resulting in scaling.
Tea tree oil
Tea tree oil has become one of the most common ingredients found in skincare products. It is known for its antimicrobial and antiseptic properties in its activity against bacteria, viruses, fungi, mites, etc. When added to scalp exfoliators it is likely addressing some of the underlying triggers for scalp inflammation that result in scaling and itching. The only caution is that it does have about a 1-2% chance of causing contact dermatitis in those who use it. If using a product that has tea tree oil and your itching and flaking are getting worse, it’s important to take a look at your products and make sure they are not making it worse!
Salicylic acid breaks apart superficial skin cells to help remove dead skin cells from the surface. It is used in acne medications but can also be found in higher concentrations in wart treatments. It can be effective without being too irritating. In scalp products, it can help remove excess dry skin and scale. Under topical therapies, we have topical steroids as the most effective with or without a vitamin D analog topical called calcipotriene and with or without a peanut oil extract to help loosen the scale. The benefit here is mostly for isolated lesions to help control the flaking and itching. If there’s lots of flaking we can also add in a salicylic acid-containing topical to help resolve the flaking. For those who struggle to apply these or feel like they just are not effective enough, we can supplement with intralesional injections of steroids locally in the skin to speed up resolution. I do remind people that there tends to be a strong stress correlation to flares and it’s important to know this to help control symptoms too!)
✔️Anti-itch indirectly by inhibiting yeast ✔️Anti-flake ✔️Anti-yeast
Selenium sulfide-containing shampoos are beneficial as selenium sulfide is both an antimicrobial and effective treatment for hyperkeratosis or thickening of the skin. Addressing the buildup and the yeast and bacteria that contribute to scalp acne is a safe and effective approach to this common problem.
**Concentrations at 2.25% and higher are available by prescription
Zinc pyrithione ✔️Anti-itch indirectly by inhibiting yeast ✔️Anti-flake indirectly by inhibiting yeast ✔️Anti-yeast
Shampoos containing zinc pyrithione are effective as this ingredient has proven antimicrobial qualities. Studies have shown that it inhibits the growth of yeast.
Coal tar is an agent that can help with itching and calm the skin as well.
Given the role of Malassezia yeast and associated inflammation, the use of an anti-yeast product such as Ketoconazole can be beneficial. The 1% concentration is over the counter whereas the 2% is considered a prescription. This is not to be confused with the oral version of Ketoconazole which is generally not intended for the purpose of treating seborrhea.
Nizoral Shampoo (1%)
*Rx available at 2%
Are there DIY recipes for at-home dandruff treatments?
At-home recipes to address dandruff usually include apple cider vinegar to address the build-up or flaking of the scalp.
Scalp Treatment Recipe for Dandruff
1/2 cup Apple Cider Vinegar 1/2 cup Water
Mix together. Massage through the scalp. Let sit for a few minutes. Rinse. If your issues are dandruff related you may need to do 1 part ACV to 1 part water as this should be able to retain more effectiveness to the yeast that triggers dandruff.