What is dandruff?

 

Dandruff is a very common disorder of the scalp that presents with flaking and peeling of the scalp. For most people dandruff is probably the most embarrassing disorders that one can get.  Dandruff is aesthetically not pleasing and it often falsely reflects poor hair hygiene. What most people do not appreciate is that dandruff can occur even in people who are meticulous about hair care.  In most cases, mild cases of dandruff can be treated with daily shampooing but chronic cases may require the use of medicated shampoos and prescription creams.

What actually is dandruff?

Dandruff is basically flakes of dry scalp. Plaques of dried scalp may develop on one side of the scalp or may be widely spread. The dried scalp breaks up into tiny pieces that are usually white to gray and can be visible on the hair or on the shoulder. In most cases, dandruff is most common behind the ears, top of the scalp and along the skin and hairline border along the forehead.

What is cause of dandruff?

- Dry skin is probably the most common cause of dandruff. Dry skin can lead to flakes. Besides the scalp dry can may also affect other parts of the body and is usually associated with itching.

- A relatively common cause of dandruff is a condition called seborrheic dermatitis. Often referred to as seborrhea, this condition tends to occur just behind the ears, scalp, face, middle of the back and chest, and along the border of the scalp hairline and skin. Seborrhea is believed to be caused by a fungus that resides on the skin. The condition can occur in both infants and adults; it often presents with patches of itchy skin and scales. Dandruff is commonly associated with seborrhea.  Seborrhea can also present with scaly plaques on the forehead, eyebrows, ear canal and under the folds of skin on the side of the nose and lips. Even though in many cases seborrhea feels scaly and dry, it is in fact oily and thus use of moisturizers is of no help in treatment.

- Individuals who do not shampoo the hair regularly can also develop dandruff. The build-up of oil and other skin debris leads to dandruff

- Skin disorders like eczema and psoriasis can also lead to build up of dead dry skin which appears like dandruff.

- Another common cause of dandruff is hypersensitivity to hair care products. Many hair products contain a vast number of chemicals that can cause contact dermatitis. This can lead to an itchy scaly scalp that can cause dandruff.

- Finally shampooing too frequently can lead to irritation and excessive dryness of the scalp which can lead to dandruff formation.

How does dandruff present?

In most people, dandruff is easily seen as white flakes of dead skin that can be seen on the hair or the shoulder. Some people may also complain of constant itching of the scalp. Dandruff generally tends to be worse during the cooler months because heat can lead to further drying of the scalp.

How does seborrhea present?

Seborrhea can present right after birth or in adulthood. In infants seborrhea typically affects the scalp whereas in adults it may affect the scalp, eyebrows, the chest and even the back. Most people complain of a mild itch and dry flakes on their hair or shoulder. A closer look will reveal redness at the site of the plaque. Despite what is reported seborrhea does not cause permanent loss of hair. In some people strands of hair will fall off when the plaque is peeled off, but the hair will grow back. Seborrhea occurs in both males and females and affects all races.

What are risk factors for seborrhea?

Seborrhea may be more common in individuals who are on certain cancer drugs, have HIV or have a depressed immune system. However, in the vast majority of people who develop seborrhea there is no cause ever found.

What is cradle cap?

Cradle cap is just another name for seborrhea that is seen in infants. It usually presents with crusty and scalp patches on the scalp and eyebrows of infants. Although it may appear frightening, seborrhea in infants is harmless and in the majority of cases disappears by the third year of life.

How is the diagnosis of seborrhea or dandruff  made?

The diagnosis of dandruff or seborrhea is made by a visual exam. Most healthcare professionals can examine the scalp and determine the presence of these two problems. There is usually no blood work required.

What is the treatment of dandruff

In general the treatment of dandruff is directed at the condition causing it. Even though there are many treatments recommended on the Internet for seborrhea, the vast majority do not work. Some people believe that they should buy more expensive shampoos or have their hair care managed different, others apply vitamin based products and then others believe that the use of hair dryers may help. In reality there is no conditioner, vitamin, herb or nutrient that can help with seborrhea.  Just because a hair product is more expensive does not mean it will work for seborrhea. No matter what shampoo one uses, there will be some improvement in seborrhea. To date there is no evidence that any hair product or hair drying worsens or improves seborrhea. Moisturizers generally do not help reduce symptoms and may even make the hair look greasy and plaques thicker and red. Seborrhea is best treated with the use of lotions and creams that contain hydrocortisone or with the use of certain topical and fungal shampoos and lotions.

The treatment of dandruff is not a one shot deal but must be done over a period of months and even years. In the majority of cases of mild dandruff, good hair hygiene and use of a gentle shampoo can decrease the oil and debris build up on the scalp. One can start with a regular shampoo for a few weeks and if that fails one can resort to dandruff shampoos. Because there are so many shampoos on the market, one may have to try out several products. Anytime you develop worsening of dandruff after a new shampoo, that product must be immediately discontinued.

What over-the-counter products can I use to treat dandruff?

Shampoos are the first line products for treatment of seborrhea. The presently available medicated shampoos available over the counter include:

• Ketoconazole (Nizoral Shampoo) is an anti-fungal shampoo and the low strength product is available without a prescription.
• Salicylic acid (T/Sal) shampoos do work in some people but excess use can lead to drying of the scalp and worsening of dandruff. It is best combined with a mild conditioner.
• Selenium sulfide (Selsun Blue) shampoos decrease the dryness but the product can also discolor hair. So rinse thoroughly after use.
• Tar (T/Gel) is coal tar shampoo that can help individuals who have seborrhea, psoriasis and dandruff.
• Zinc pyrithione (like Head & Shoulders) has both antibacterial and anti-fungal properties. While it can reduce dandruff, excessive use can lead to drying of the scalp and worsening of dandruff.

There is no difference in efficacy between these shampoos. The shampoo can be used regularly or just once or twice a week, depending on the severity of the symptoms. In most cases, if the shampoo works and the symptoms subside, use the medicated shampoo regularly. In some cases, one shampoo may work for a while and then stop working. In such cases one may need to switch to another shampoo. Some individuals may benefit from two different medicated shampoos.

What medicated creams are available for seborrhea?

Creams are the next option when shampoos fail to work; there are two types of medicated creams for seborrhea- hydrocortisone and anti-fungal creams.

The corticosteroid creams can decrease scaling and inflammation rapidly. The lighter strength products are available over the counter. Corticosteroid creams are relatively safe to use on the face and within days one can see the benefits. The cream is used once on the scalp after shampooing and twice on the face. The creams can also be combined with the medicated shampoos.

Similarly the over the counter anti-fungal creams are also effective. They need to be applied once or twice a day.

Both creams have to be continued until the symptoms subside. If the seborrhea recurs, then the creams should be restarted

What are other options if over the counter agents do not work?

In general, one must try and use over the counter products for a few weeks to see a response. If that fails, then one needs to see a primary care physician or a dermatologist who may prescribe corticosteroids, anti-fungals or a potent medicated shampoo. These products are effective but should not be used directly on the face, eyes or nose area. There are many formulas of corticosteroids available such as gels, liquids, foams and creams that can be applied to the scalp. Most of these agents are clear products that can be used during the daytime and also are not greasy.

There are also some non-steroidal formulas such as tacrolimus and pimecrolimus which are useful for chronic seborrhea. They tend to be more expensive than the steroidal medications.

Can seborrhea be cured?

It is important for individual with seborrhea to understand that all medicated shampoos and corticosteroid lotions can decrease the inflammation and scaling. However, once the medication is discontinued, recurrence is common. These prescription products have to be used regularly for maximal benefit.

How does one treat seborrhea of the eyelashes?

Dandruff or seborrhea of the eyelashes can be very difficult to treat. Healthcare professionals recommend that instead of just applying the medicated shampoo on the eyelash, it is important to use a Q-tip to apply the medication on the individual eyelash. Because corticosteroids have undesirable effects on the eye, all individuals with seborrhea of the eyelashes should only use these agents under supervision of a healthcare provider.

Are there any home remedies to decrease seborrhea?

Yes, one should avoid stress, shampoo regularly; reduce excessive hair styling, dyeing, waxes and mousses.

Eat a healthy diet consisting of fruits and vegetable and expose your hair to sunlight.