Scalp itching and flaking is most commonly caused by a condition called seborrheic dermatitis, otherwise known as dandruff or if we are really getting fancy pityriasis simplex capillitii.
What causes it?
Seborrheic dermatitis is caused by a yeast that lives on human skin called Malassezia furfur. This yeast under the microscope looks like little spaghetti and meatballs. It does not cause any harm and does not cause any internal problems. But it can be quite frustrating when you are trying to wear a black shirt or a black suit and there’s little tiny white flakes all over.
Who gets it?
The most common location for seborrheic dermatitis is the scalp but it can also present on the face and central chest, areas where there’s a lot of sebaceous glands (oil glands). It can happen to anyone, starting from little babies (cradle cap) to adults. Men seem to get it more commonly than women. No one really knows why some people are more prone to getting recurrent bouts of dandruff whereas others never get it all. Studies point to possible differences in the oil or lipids on the skin as to a possible cause of seborrheic dermatitis although more studies need to be done. Stress and dry winter weather are triggers for flares for some people. Certain diseases also puts patient at higher risk of getting more severe seborrheic dermatitis such as HIV or Parkinson’s disease.
What are some possible treatment options?
As it is a benign condition – meaning there’s no harm to having it. Thus, there is no need to treat it. But it can surely be annoying, so treatment is available. There are some options over the counter and prescription options. Usually shampoos are recommended either daily or 3x/week for several weeks until the scalp is clear, then 1x/week for maintenance to prevent relapse. If there is evidence of dandruff on the face, sometimes topical steroids or topical calcineurin inhibitors (pimecrolimus or tacrolimus) may be used twice daily on face until skin clears. Shampoos may also be used on the face and chest as a face wash or body wash in the same manner as the scalp treatments; either daily or 3x/week. Rarely, oral medications may be used in severe cases.
Over the counter topical options:
- Mustela Newborn Baby Foam Shampoo for Cradle Cap (for babies)
- Selenium sulfide (ie. Selsun Blue).
- Pyrithione Zinc (ie. Head and Shoulders)
- Ketoconazole 1% (ie. Nizoral)
- Tar shampoo (ie. Neutrogena tar shampoo, DHS)
- Salicylic acid shampoo (i.e Neutrogena salicylic acid shampoo, DHS)
- Ketoconazole 2% shampoo
- Ciclopirox 1% shampoo
- Fluocinonide solution or clobetasol solution – twice daily for 2-4 weeks for itch/scaling
- Hydrocortisone 2.5% cream – twice daily for 2 weeks on face
- Pimecrolimus cream (Elidel) or tacrolimus ointment (Protopic) – twice daily for 2-4 weeks on face
There’s not enough evidence to recommend oral anti fungals for treatment of seborrheic dermatitis, however for severe cases, sometimes oral ketoconazole, itraconazole, fluconazole, or terbinafine may be prescribed for short duration (i.e. itraconazole PO 200 mg daily x 7 days).
In summary, dandruff or seborrheic dermatitis is very common and there are many treatments available. Sometimes this condition can be mis-diagnosed as there are other causes of itchy, flaky scalp such as scalp psoriasis. I recommend first trying the topical medications at your local drug store but if that does not do the trick, then ask your dermatologist for further recommendations.
I am a board certified dermatologist at Cedars-Sinai in Los Angeles. I am a comprehensive dermatologist caring for families. I love seeing children and adults. My youngest patient was 0 days old and my oldest was 110 years old. I have had psoriasis since the age of 8 and considered an expert in psoriasis and psoriasis treatments. I have lectured locally and nationally and published numerous papers on other topics such as skin manifestations of eczema, hidradenitis suppurativa, systemic lupus erythematous, granuloma annulare, microbiome, skin cancers, and more. My expertise includes knowledge in managing complex skin diseases. I am experienced with surgical treatment of skin cancers, as well as non-surgical methods to treat skin cancer and precancerous lesions. I run a full medical, cosmetic, and surgical dermatology practice. I am experienced with the use of complex dermatologic therapy, including biologic therapy, immunosuppressive medications, and phototherapy. I also treats fine lines and wrinkles non-surgically with combinations of botox, fillers, chemical peels, lasers, and radiofrequency. I perform minor surgeries such as excisions for cysts, lipomas, basal cell skin cancer, squamous cell skin cancers, and early stage melanoma. I am physician expert for Kopa for Psoriasis, part of Happify. I have been featured on podcasts and quoted in numerous online and print publications. I am honored to be named “Top Doctor” in Los Angeles magazine. In my free time, I volunteer for community events such as skin cancer screenings and at the local free clinics. I also teach internal medicine and dermatology residents at several academic centers. I try to do yoga every day and every year, I run a half-marathon at the Golden Gate Bridge.