- Dandruff is produced when the skin of the scalp exfoliates excessively.
- The white dusty flakes of material in the hair and on the shoulders are fragments of the superficial stratum corneum.
- Lack of shampooing can enhance dandruff by allowing flakes to accumulate on the hair.
- There are a number of scalp diseases than can produce dandruff.
What is dandruff?
Those unpleasant white flakes on the collar of your dark shirt or blouse are dandruff. Dandruff is a sign that the skin of the scalp is peeling off (exfoliating). It is perfectly normal for the skin to exfoliate. The problem arises when the amount of dandruff becomes an eyesore. There are basically two reasons for this. Too much production or not effective removal. In the too much production category are inflammatory diseases of the scalp. In the ineffective removal category is inadequate scalp hygienic efforts.
What specialties of doctors treat dandruff?
Primary-care providers and nurse practitioners are be able to diagnose and treat most cases of dandruff. Dermatologists are experts in skin diseases.
Dandruff is believed to be related to a fungus known as Malassezia (formerly termed pityrosporum) that lives on the scalp of most people. In some cases, overgrowth of the fungus results in the flakiness of the skin characteristic of dandruff. The reasons for the overgrowth of fungus are unclear but may be related to increased oil production, hormonal changes, stress, neurologic disorders such as Parkinson's disease, recovery from chronic conditions such as stroke or heart attack, suppression of the immune system, and infrequent shampooing.
What are the causes of dandruff? What are dandruff symptoms and signs?
Dandruff itself produces no symptoms. However, the most common cause of dandruff, seborrheic dermatitis (seborrhea), is an itchy red rash that tends to occur on the scalp, ears, face, mid-chest, and mid-back. The cause of seborrhea is unknown, although a yeast that often lives on the skin, Malassezia furfur, may play a role.
The most common secondary manifestation of seborrhea of the scalp is dandruff. Seborrhea produces plaques of itchy red skin with scaling. It is the accumulated scale that we call dandruff. Reddish, scaly plaques may also appear in the eyebrows, on the forehead, in the ear canal, on the folds of skin that extend from the nostril to the commissure of the lips. Although skin affected by seborrhea may feel and look dry, this is not the case; moisturizers are of little help in its control.
Scalp seborrhea may slow hair growth but does not cause permanent hair loss. Often, scalp seborrhea doesn't even itch significantly. Seborrhea can appear during infancy, starting shortly after birth and lasting several months. It may affect the scalp ("cradle cap") or produce scaly plaques on the body. Seborrhea may occur at any age.
Some people who have weakened immune systems, such as those on chemotherapy or those with HIV disease or certain neurological disorders, may have very severe seborrhea. It is important to emphasize, however, that seborrhea is a very common condition, affecting perhaps 5% of the population (with men predominating). The vast majority of those who have it are completely healthy and have no internal or immune problems.
There are a variety of other inflammatory diseases that can produce excessive scaling and therefore dandruff, including psoriasis, fungal infection of the scalp skin (tinea capitis), and allergic contact dermatitis.
How do doctors diagnose the cause of dandruff?
After a thorough scalp examination, the cause of most cases of dandruff is usually apparent. Occasionally, physicians may find it necessary to perform a scalp biopsy where a small amount of scalp skin is removed under local anesthesia and submitted for examination under a microscope.
See pictures of dandruff and other hair and scalp conditions
What treatments are available for dandruff?
Treatment of seborrhea (dandruff) is directed at fighting the skin inflammation. This is done either directly, by using cortisone-based creams and lotions (which reduce inflammation), or by using topical anti-yeast lotions and shampoos. Treatment should be directed at the cause of the dandruff.
What doesn't help dandruff?
- Moisturizing: Moisturizing lotions don't do much more than smooth out scales and make plaques look redder.
- Switching brands of shampoo: Shampoo doesn't cause dandruff. However, medicated shampoos (see below) can help.
- Changing hair-care routines: There is no "right" shampoo or conditioner. What is more important is the frequency with which these agents are used. As a rule, the more frequently one shampoos, the better the result. Seborrhea and dandruff are not caused by excessive shampooing "drying out the scalp." Hair dyes and conditioners do not cause or aggravate dandruff.
- Switching antiperspirants: When underarms are red from seborrhea, almost anything will make them redder, including antiperspirants, even though they are only aggravating the seborrhea and not causing it.
Are there home remedies for dandruff?
- Shampoos: Here are some ingredients in medicated shampoos that can help control dandruff of the scalp. All are available over the counter.One can use any of these either all of the time or just once or twice a week, depending on how severe the symptoms are. If the problem quiets down or disappears, use unmedicated shampoos. If one kind of shampoo works for a while and "runs out of gas," switch to another. For resistant cases, alternate two different types.
Many people, especially the elderly, believe that it may be harmful to shampoo frequently. Some avoid washing their scalp for more than a week. However, it is very unlikely that daily shampoos will produce any untoward effects other than removing dandruff.
- Topical steroids: Two additional types of medication that help seborrhea are cortisone creams and antifungal creams.
- Corticosteroid creams and lotions reduce inflammation. These can be purchased over the counter in either 0.5% or 1% concentrations. They are safe to use on the face and will often help in just a couple of days when applied twice daily. These products also are available as scalp lotions that are applied once a day, preferably on damp hair after shampooing. One can use scalp corticosteroid creams together with medicated shampoos.
- Antifungal creams are often effective, apparently because they reduce the number of yeast organisms living on the skin. Over-the-counter creams include 1% clotrimazole cream and miconazole cream 2%. Antifungal creams also are applied once or twice a day.
As with shampoos, creams should be applied until the seborrhea subsides. When the seborrhea comes back (and it will, sooner or later), the creams should be used again.
Fight Dandruff: How to Treat, Control, and Prevent Flakes
If over-the-counter products don't work, what can the doctor prescribe for dandruff?
A primary-care physician or dermatologist can recommend prescription-strength shampoos or antifungal and corticosteroid creams that are stronger than those available over the counter, yet are not too strong to use on the face. There also are corticosteroid-based liquids, gels, and foams that one can apply to the scalp that won't leave the hair limp and matted. Nonsteroid preparations like tacrolimus (Protopic) or pimecrolimus (Elidel) may also help.
What is the prognosis of dandruff?
Most simple uncomplicated dandruff responds to frequent shampooing. As with all seborrhea (dandruff) treatments, medicated shampoos and cortisone creams calm down the skin or scalp sensitivity, but they can't permanently stop the seborrhea (dandruff) from coming back. Most people, however, only have to treat their condition from time to time when it becomes itchy or noticeable.
A word on eyelashes
Dandruff (seborrhea) of the eyelashes can be both annoying and hard to treat. Eye doctors like to recommend scrubbing the lashes with baby shampoo on a cotton swab. Corticosteroid-based lotions should be used close to the eye only under medical supervision since continuous exposure of the eye to these products can lead to serious eye problems.
Is it possible to prevent dandruff?
Yes. Frequent shampooing will prevent most cases of dandruff.
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Dessinioti, Clio, and Andreas Katsambas. "Seborrheic Dermatitis: Etiology, Risk Factors, and Treatments: Facts and Controversies." Clinics in Dermatology 31 (2013): 343-351.
Turner, G.A., M. Hoptroff, and C.R. Harding. "Stratum Corneum Dysfunction in Dandruff." International Journal of Cosmetic Science 34 (2012): 298-306.