How to treat dandruff in adolescents and adults

Since causes are not very well defined as yet, there is currently no clinical treatment aimed at curing dandruff. With research still ongoing, for now, dandruff causes appear to be multifactorial and varied.

That said, it has been noted that antifungal therapies are generally able to effectively control dandruff conditions, even though fungal microbials have not yet been conclusively proven to be a direct cause. Thus, such therapies are typically used as first-line treatment for mild and more severe flaking / scaling conditions.

Cosmetic management (topical treatment) is the best way to treat the symptoms of the condition and keep it relatively under control. Dandruff is considered a chronic condition requiring life-long management.

1. Treatment recommendations for mild dandruff

Mild dandruff without inflammation (i.e. dandruff that is subclinical) is most often treated with the following:

Antifungal and antiproliferative shampoos (i.e. medicated dandruff shampoos) ⁽⁹⁾

• Effective ingredients (available through prescription): 2% Ketaconazole (Nizoral shampoo) and 1% Cicliprox (Loprox shampoo) – It is recommended that these shampoos be used twice weekly for at least 4 weeks. To prevent relapses, it is recommended that these be used once a week thereafter.
• Effective ingredients (available over-the-counter): 1% Zinc Pyrithione (Head & Shoulders, Zincon or DHS zinc) and 2.5% Selenium Sulphide (Selsun or Exelderm), a heavy metal salt. As with the prescription-based varieties, use is recommended twice weekly for an initial 4-week period, and thereafter at least once a week.

Ketoconazole is a white or colourless organic imidazole compound that is water soluble. The compound acts predominantly as an antifungal agent (helping to reduce microbial accumulations), but also has a mild anti-inflammatory effect. This makes shampoos containing it fairly effective in managing mild dandruff conditions. Ciclopirox is also a synthetic antifungal agent which can effectively treat mild symptoms of dandruff.

Both ingredients are easily absorbed into the scalp and have shown a low rate of irritancy or sensitivity when in contact with the skin. Shampoos containing Ketoconazole do appear to have a higher success rate for preventing frequent dandruff relapses than many over-the-counter shampoo varieties.

Zinc Pyrithione and Selenium Sulphide ingredients are considered antiproliferative shampoos which can help to inhibit skin cell growth. This also helps to reduce scalp irritation, itching and flaking. An alternative antiproliferative ingredient is (coal) tar (Z-Tar, DHS tar, Pentrax, T-Gel extra and Ionil T plus).

The use of these shampoos more frequently than once or twice weekly is not recommended as studies have not shown this to be a more effective way to control dandruff. If tolerable, daily shampooing is not generally harmful to the scalp but the recommended use frequency is usually sufficient for adequate long-term control of mild conditions.

Conditioner rinses containing zinc or topical oils such as fluocinolone or acetonide (synthetic corticosteroids) can help to reduce erythema (redness), itching and mild swelling. Oils can be applied to the scalp in small amounts, massaged in and left overnight. These oils can also help to soften any thick flakes or scales.

Tea tree oil

A ‘natural’ remedy, tea tree oil (Melaleuca oil) has been researched as an alternative option for the management of dandruff symptoms. Research has focussed on demonstrating the antimicrobial and anti-inflammatory effects of the oil (including its components) in a clinically effective way. ⁽¹⁰⁾

Tea tree oil products (at 5% concentration) may be effective for some individuals with mild to moderate dandruff, helping to reduce itching and redness as well as controlling greasiness. Tea tree oil is usually relatively well tolerated by most users, but it is associated with some allergic skin reactions or skin irritant sensitivities. Using lower concentrations of the oil can sometimes help to curb this.

Research studies relating to its use for dandruff have not seemingly been able to clinically prove that tea tree oil can be used effectively in all sufferers. Many of the studies are also limited in that they were conducted with a low number of participants, with a few achieving positive responses. If tolerable to an individual, it may be beneficial in helping to reduce some of the symptoms associated with mild to moderate dandruff.

2. Treatment recommendations for moderate to severe dandruff or SD

In individuals with more moderate to severe symptoms including scalp inflammation, itching (or even burning sensations), dryness and large or thicker flakes or scales, the following (combination) treatment is recommended:

• Antifungal shampoos: 2% Ketoconazole shampoo used once or twice a week (for moderate cases of dandruff) or once daily (sometimes twice for more severe conditions). Ciclopirox (1%) can also be helpful. For severe dandruff, daily applications (once or twice) can help to improve itching, redness and scaling within 4 weeks. ⁽¹¹⁾
• Topical corticosteroid - ointment, oil, spray or foam (high-potency): These products (often hydrocortisone, betamethasone or desonide) may be prescribed for use once a day for between two and four weeks. Use will not be recommended over the long-term as these medications do carry a risk of becoming ineffective after longer periods of time. Some side-effects of use can also include mild skin irritation (itching, dryness or burning sensation), swollen hair follicles, temporary hair loss, skin atrophy (or thinning), ‘spider veins’ (telangiectasia), skin discolouration and the formation of blisters, pimple-like lesions or crusting of the treated scalp / skin area.

Combination therapy is aimed at reducing the more visible signs and symptoms of moderate to severe dandruff (or seborrheic dermatitis), as well as providing effective long-term maintenance. Treatment is primarily topical and includes the use of topical antifungal / antimicrobial products (shampoos) with a mild anti-inflammatory effect, as well as anti-inflammatories (corticosteroids) further helping to ease any discomfort experienced.

Topical calcineurin inhibitors (tacrolimus or pimecrolimus) may be used as an alternative to topical corticosteroids. These immunosuppressants also have an anti-inflammatory effect, but with fewer adverse reactions than topical corticosteroids and can be used for longer periods.

Ketoconazole is also available as a 2% cream (Nizoral) or foam (Extina) for topical application use. Coal tar shampoos, or those containing salicylic acid can also be used as an alternative to the ketoconazole option. These ingredients help to soften thickened flakes or scales and remove them from the scalp completely.

Other topical agents (cream, ointment, gel, soap or shampoo) which a doctor can also consider include:

• Selenium sulphide
• Zinc pyrithione
• Lithium succinate (lithium salt of succinic acid) or gluconate - topical application at 8%

Oral antifungal therapies (itraconazole, ketoconazole, fluconazole and terbinafine) can also sometimes be recommended when a doctor is presented with a patient that is not able to achieve sufficient condition control with topical agents, or displays symptoms affecting multiple areas of the body as well as the scalp.

Those with severe dandruff / seborrheic dermatitis may benefit from refraining from the use of the following medications which are known to induce flare-ups:

• Auranofin (gold-containing salt medication, usually taken orally for the treatment of rheumatoid arthritis) and Aurothioglucose (a gold thioglucose, also used in the treatment of rheumatoid arthritis)
• Buspirone (used in the treatment of anxiety / generalised anxiety disorder)
• Chlorpromazine (used to treat mood disorders such as schizophrenia)
• Haloperidol, thiothixene and phenothiazines (antipsychotic medications)
• Lithium (used in the treatment of depressive disorders)
• Cimetidine (a histamine H₂ receptor antagonist commonly used for heartburn and peptic ulcer treatment)
• Ethionamide (an antibiotic commonly used in the treatment of tuberculosis)
• Fluorouracil (used in the treatment of cancers affecting the colon, oesophagus, breast, cervix, stomach, pancreas and stomach)
• Gold (this injectable treatment is sometimes used for arthritic conditions – rheumatoid and psoriatic)
• Griseofulvin (used to treat fungal infections of the skin and nails)
• Interferon alfa (an antiviral or antineoplastic agent used to treat follicular lymphoma, Kaposi’s sarcoma and malignant melanoma)
• Methoxsalen (used in the treatment of eczema, psoriasis and vitiligo)
• Methyldopa (used to treat high blood pressure / hypertension)
• Psoralens (used to help absorb ultraviolet light in combination with PUVA ultraviolet light therapy for skin conditions like vitiligo, psoriasis and eczema) and trioxsalen.
• Stanozolol (a steroid medication used in the treatment of hereditary angioedema and sometimes as an anabolic steroid among bodybuilders)

Care tips for using andti-dandruff shampoos

The proper application of anti-dandruff shampoo involves longer lathering of the scalp during shampooing (with shampoo being left on the scalp for 5 to 10 minutes before rinsing completely) in order to gain the maximum benefit from the active ingredients.

The discontinuation of topical hair styling products such as hair sprays, gels and waxes etc., hair styling tools like blow-dryers and hair colouring dyes, which can aggravate scalps affected by dandruff is recommended.

Some scalp irritation or a mild burning sensation can sometimes be experienced as side-effects of antifungal / medicated shampoo usage. If this occurs, consult with your doctor or pharmacist.

Cradle cap treatment

For babies with skin scaling conditions, the treating doctor will typically assess the severity of the cradle cap present during a consultation before recommending treatment. As with mild to moderate or more severe dandruff (or seborrheic dermatitis of the scalp) in adolescents and adults, medicated shampoos are typically recommended for clearing cradle cap in babies.

A doctor will likely recommend application guidelines like:

• Gently massaging the baby’s scalp using one’s fingers (with short nails) or a soft brush so as to help loosen any scales that have developed. Massage has the added benefit of improving circulation in the scalp.
• Scalp massage and shampooing may be recommended on a daily basis until it appears that a baby’s condition has gone into remission (i.e. there are no more scales present). Thereafter the shampoo can be used twice weekly. The baby’s head must be thoroughly rinsed after each shampooing.
• A baby’s hair can be brushed with a soft and clean brush after shampooing. The brush must be washed with soap and warm water each time it is used for brushing. This will ensure that any scalp oils and scales are cleaned from the brush before it is used again.

If a baby’s scalp does not show improvement or a little one is still scratching, and / or develops a fever, it is best to consult a physician for re-examination. A fever may indicate an infection and require antibiotic treatment.

Potential treatment considerations for the future

While antifungal therapies may be the most beneficial in the treatment of dandruff at present, topical products for anti-dandruff use are yet to directly address stratum corneum (epidermal barrier) dysfunction, TEWL (which increases and lipid level changes in susceptible individuals), amongst other causal associations. Treatment in current use does help to gradually reduce or remove microbial irritants, stimulate the normalisation of cellular renewal process and assist with scalp recovery, but may not directly treat other possible causal agents as yet.

The use of anti-dandruff shampoos and products can sometimes be harsh on the scalp and undermine the effectiveness of the anti-dandruff topical treatment being used. This can result in post-wash tightness, scalp dryness, irritation and itching as well as further dysfunction of the stratum corneum barrier.

Further research may be focused around providing multi-functional treatment with topical products that directly stimulate stratum corneum barrier health and integrity (via barrier lipid replenishment), as well as provide antifungal / antibacterial and anti-inflammatory benefits. 

References:

^{9. US National Library of Medicine National Institutes of Health. May 2011. Adult Seborrheic Dermatitis - A Status Report on Practical Topical Management: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3100109/ [Accessed 12.03.2018]}

^{10. US National Library of Medicine National Institutes of Health. January 2006. Melaleuca alternifolia (Tea Tree) Oil: a Review of Antimicrobial and Other Medicinal Properties: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360273/ [Accessed 12.03.2018]}

^{11. US National Library of Medicine National Institutes of Health. April 2015. Topical antifungals for seborrhoeic dermatitis: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4448221/ [Accessed 12.03.2018]}