Management of dandruff

Dandruff also known as seborrheic dermatitis is the disorder of sebaceous glands. [1]

• environmental factors (e.g. pollutions, humidity)
• genetic predispositions
• causative organism: Malassezia spp. (also known as pityrosporum ovale) 
• trauma, emotional stress [2]

Regardless of its aetiology, many products are being marketed for dandruff treatment currently. The most common and widely commercialised shampoos are classified according to their contents of anti-dandruff ingredients.  [3]

1. Selenium Sulfide 1 % (Selsun Blue)
2. Pyrithione Zinc 1 % (Head & Shoulders)
3. Ketoconazole 1 % (Nizoral)
4. Cetrimide solution as shampoo

Besides shampoos, topical preparations are also available. These are antifungals and can be applied once or twice daily.  [3]

1. Clotrimazole cream 2 %
2. Miconazole cream 2%
3. Terbinafine solution 2%

For severe conditions, keratolytics may be needed. Salicylic acid or coal tar preparations would in this case remove the dense scales. And after removal of the latter, steroidal preparations can be applied sparingly to help soothe the inflammation.  [3]

Treatment:

• Keratolytics to remove scale used when necessary, eg salicylic acid, lactic acid, urea, propylene glycol
• Topical antifungal agents to reduce Malassezia eg ketoconazole, or ciclopirox shampoo or and/or cream. Note, some strains of Malassezia are resistant to azole antifungals. Try zinc pyrithione or selenium sulphide
• Mild topical corticosteroids for 1-3 weeks to reduce inflammation in acute flare
• Topical calcineurin inhibitors (pimecrolimus cream, tacrolimus ointment) as required
• In resistant cases in adults, oral itraconazole, tetracycline antibiotics or phototherapy may be recommended.

Scalp Treatment

• Medicated shampoos containing ketoconazole, ciclopirox, selenium sulfide, zinc pyrithione, coal tar, and salicylic acid, used twice weekly for at least a month and if necessary, indefinitely.
• Steroid scalp applications reduce itching, and should be applied daily for a few days every so often.
• Tar cream can be applied to scaling areas and removed several hours later by shampooing

Face, ears, chest & back

• Cleanse the affected skin thoroughly once or twice each day using a non-soap cleanser.
• Apply ketoconazole or ciclopirox cream once daily for 2 to 4 weeks, repeated as necessary.
• Hydrocortisone cream can also be used, applied up to twice daily for 1 or 2 weeks. Occasionally a more potent topical steroid may be prescribed.
• Topical calcineurin inhibitors such as pimecrolimus cream or tacrolimus ointment may be used instead of topical steroids

Administration

• To get the most out of these shampoos, it should be left on the scalp for 5-10 minutes daily and then followed by twice weekly application. 
• Many fail to realise the importance of the time frame that the shampoo should be left on in contact with the scalp. 
• In some cases, despite faithfully shampooing and following directions the shampoo might start to be ineffective. In this case, 2 shampoos can be used and it is advised to alternate between them.  [1]
• Cetrimide can be used with concentrations of 10-20 %. Once the scalp is wet with warm water, cetrimide can be massaged into the scalp and rinsed. A second application and rinsing is encouraged. This can be done 2-3 times a week.

References:

1. Mayo Clinic. Dandruff treatment and drugs. 2015 Mayo foundation for medical education and research. Available from: http://www.mayoclinic.org/diseases-conditions/dandruff/basics/treatment/con-20023690
2. Nowicki R. Modern management of dandruff. Pubmed. 2006 Jan; 20(115): 121-4.
3. Johnson BA et al. Treatment of seborrheic dermatitis. Am. Fam. Physician. 2000 May1; 61(9): 2703-10.
4. NetDoctor. 2014. available from:  http://www.netdoctor.co.uk/skin-and-hair/medicines/ceanel-concentrate.html
5. http://dermnetnz.org/dermatitis/seborrhoeic-dermatitis.html