Scalp problems or conditions can be minor issues or infections that affect the skin on the top of the head. Dandruff and oily scalp are the most common problems. Luckily, these conditions can be treated or controlled with over the counter solutions. However, a scalp condition can also be much more serious and persistent often requiring a visual consultation with a physician specializing in skin and scalp disorders. Depending on the severity of the condition, a physician will be able to prescribe a treatment plan that will offer relief from irritation and discomfort.
The most common and widely recognized type of scalp scaling is the condition known as “dandruff”. Almost everyone has experienced “dandruff” at some time-usually in the appearance of whitish to yellowish-white flakes on clothing and bedding as well as clinging to hair. The normal loss of “dead cells” from the scalp is usually imperceptible or nearly so. The cells of the epidermis (outer skin layer) of the scalp are replaced about every 27 days; the “dead” cells scale off as they are replaced by new cells. Usually, not enough cells are shed at any one time to become noticeable.
“Dandruff” is regarded as unsightly and socially embarrassing. A great many proprietary shampoos, lotions and ointments are marketed as “anti-dandruff” treatments. Although “dandruff” is the all-encompassing term for scales shed from the scalp, there are a number of different and distinct causes of scalp scaling. Some should receive medical diagnosis and treatment.
Scalp scaling becomes noticeable, and an embarrassing problem, when either there is an increase the rate of turnover in scalp epidermal cells or when the size of shed flakes and increased scalp oiliness causes dead cells to adhere together into clumps.
The most common, and usually unprogressive, type of scalp scaling (pityriasis-shedding of bran-like flakes) is a slight increase in turnover on epidermal cells, with or without an increase in scalp oiliness (seborrhea).
At various times there have been suggestions that this mild form of pityriasis is associated with microorganisms on the scalp-specifically a yeast Pityrosporum ovale. This has never been definitively established. Mild pityriasis can usually be managed with regular shampoos about once a week.
This kind of scaling can be controlled by the use of anti-dandruff shampoos. This treatment is more successful for some persons than for others and if the flake shedding is successfully managed, there is no need to consult a physician. However, many of the other conditions that cause scalp scaling require medical diagnosis and treatment.
Some of the causes are manifestations on the scalp of systemic diseases such as psoriasis or hormonal dysfunction. The size, form and color of the scalp scales can suggest a diagnosis. For example:
- Pityriasiform (bran-like) flakes are characteristic of mild pityriasis or “dandruff”.
- Brittle flakes in several loose layers suggest psoriasis.
- A fish-scale form suggests the skin disease ichthyosis.
- Lichenoid scales suggest a skin disease such as lichen planus.
- Waxy, greasy, yellowish-brown scales suggest seborrhea.
- Excessively heavy scaling, scalp oiliness, open lesions on the scalp, and unrelieved scalp itching are all indications to consult a physician.
Abnormally heavy scaling, excessive scalp oiliness, open lesions on the scalp, and unrelieved scalp itching are all indications to consult a physician.
(For information about scalp disease from dermatologists, visit the website of the American Academy of Dermatology.
The moderate skin-flaking that constitutes “dandruff” for most people is easily controlled by frequent shampooing. The shampooing may be done every 1 to 3 days, depending on the frequency necessary to control excessive flaking. No special shampoo is needed for this moderate level of dandruff control.
If excessive flaking and scaling is not controlled by shampooing with your regular product, you may want to try an over-the-counter dandruff control shampoo. There are five different basic formulas based upon their principal active ingredient. You may have to try several before you find one that works best for you. All of the dandruff control products can cause minor side effects such as skin irritation. If you have skin allergies, you may wish to check with your physician before using a dandruff control shampoo.
Sometimes a dandruff control shampoo that relieves excessive scalp oiliness will cause excessive scalp dryness and dry-skin flaking-replacing one cause of dandruff with another. Dry-skin flaking can usually be controlled by using a hair conditioner after the dandruff control shampoo (See Healthy Hair).
|Active Ingredient||Principal Anti-Dandruff Activity||Brand Names|
|Selenium sulfide||Slows skin cell turnover (flaking)
|Head and Shoulders Intensive Treatment Dandruff Shampoo
Head and Shoulders
|Coal-tar base||Slows skin cell turnover (flaking)
Controls excessive skin oiliness
Removes psoriatic scales
|Salicylic acid||Slows skin dell turnover (flaking)
Controls excessive skin oiliness
|Ketoconazole||Antifungal (Stronger formula available by prescription)||Nizoral|
*Always follow instructions on the label for best results
Psoriasis is an inflammatory, systemic skin disease characterized by red, scaly lesions that may involve portions of the body or nearly the entire body. A genetic predisposition is indicated by the number of psoriatic patients who have relatives with psoriasis. While the underlying cause of psoriasis is still unknown, considerable evidence points to dysfunction of the immune system as a cause or contributing factor.
While psoriatic lesions can appear anywhere on the body, the scalp is one of the most frequent sites. The scalp may be the first site affected in children and young adults, and in some persons, it remains the only site affected.
Psoriasis has many levels of severity and many different clinical features ranging from shedding of grayish scales to pustular eruptions. Severe forms of psoriasis may be associated with other inflammatory conditions, especially psoriatic arthritis and inflammatory bowel disease.
Psoriasis of the scalp usually has a distinctive appearance of inflamed skin overlain with silvery scales. In severely progressive disease the psoriatic lesions may merge into a solid mass of scales over the entire scalp, with temporary or permanent hair loss. Psoriasis of the scalp and seborrheic dermatitis of the scalp have many features in common and maybe confused unless properly diagnosed. Atopic dermatitis, an inflammatory, extremely pruritic skin disease, may also resemble psoriasis; scalp involvement in atopic dermatitis is more frequent in infants and children but does occur also in adults. Because treatment is different for each of these diseases, correct diagnosis is essential to appropriate treatment.
Authoritative information about psoriasis and specifically psoriasis of the scalp is available at:
Allergic and irritant contact dermatitis of the scalp is experienced by millions of people every year. Contact dermatitis is characterized as an inflammatory, often itchy, condition caused by reaction of the skin after contact with a sensitizing external agent.
The classic example is the itchy and blistered skin that follows contact with poison ivy. Other agents causing allergic and irritant contact dermatitis range from:
- Workplace chemicals
Irritant contact dermatitis usually appears immediately or soon after contact with an irritant agent. Allergic contact dermatitis characteristically appears upon encountering an agent that previously came into contact with the skin; an allergic response usually requires sensitization by an initial encounter with the allergenic agent.
Hair dyes or ingredients of hair-care products such as straighteners, permanent wave solutions, tonics, etc., are the external agents most frequently responsible for allergic or irritant contact dermatitis of the scalp. While major manufacturers strive to eliminate any irritating or allergic potential from their hair-care products, some individuals may have skin characteristics that predispose them to inflammatory or allergic reactions to certain sensitizing agents. “Home-made” products such as lye-based hair straighteners are not safety tested and can have significant potential for causing contact dermatitis. Irritant contact dermatitis is characterized by inflammation and burning sensations soon after contact with an irritant agent. Severe, persistent inflammation may result in temporary or permanent hair loss. The condition usually resolves over time, after withdrawal of the irritant. Persistent dermatitis should be treated by a physician.
Allergic contact dermatitis can have varying presentations ranging from mild scalp inflammation to chronic eczema and involvement beyond the scalp to inflammation and edematous swelling of the face and neck. Unlike irritant contact dermatitis, allergic contact dermatitis can persist for days to weeks after withdrawal of the allergenic agent. Persistent allergic contact dermatitis requires medical treatment.
Itching of the scalp can occur with any of the conditions that cause scalp scaling. Other causes of scalp itching include:
- Contact dermatitis-irritation or allergic reaction associated with contact with an offending agent such as hair bleach, coloring solution, or permanent wave solution.
- Eczema occurring on the scalp; the type of eczema called atopic dermatitis is a systemic disease requiring medical diagnosis and treatment.
- Acne on the scalp.
- Lichen simplex, a localized thickening and “itchiness” of the skin caused by persistent rubbing or scratching of the apparently normal skin.
- Head Lice – the head louse is a very small parasitic insect that lives among human hairs and feeds on very small amounts of blood drawn from the scalp. Head lice (the plural of louse) are a very common problem for kids ages 3 years to 12 years and often see more commonly among girls than boys. Head lice are not dangerous and don’t spread disease, but are extremely contagious. Their bites may cause a child’s scalp to become itchy and inflamed, and persistent scratching may lead to skin irritation and even infection.
For more information, see the American Academy of Dermatology Website.
Sebum is the oily substance secreted by sebaceous glands in the skin. This oil on the skin has the protective function of keeping skin from losing moisture and becoming excessively dry and providing a layer of defense against infectious microorganisms.
Seborrhea is the excessive production of sebum. It is important to note that the definition of “excessive” varies with the age and gender of the individual. Sebum production is influenced by age, sex, and hormonal status.
Because the largest sebaceous glands are on the face, scalp, and groin, these areas are subject to become excessively oily due to seborrhea. All sebaceous glands distribute sebum through a connection to hair follicles, making sebaceous glands and hair follicles the functional units for dispensing sebum to the surface of the skin. The anatomical proximity of sebaceous glands and hair follicles explains why oily skin and oily hair usually occur together in seborrhea. Sebum production is largely controlled by the hormones with the androgenic male hormones playing a central role in both males and females. As males begin to mature into adulthood at about age 13 to 16, androgen levels rise and sebum production increases. Sebum production reaches its highest level in males at about 20, and then slowly declines as male’s age. It is interesting to note that Sebum production remains higher in healthy females but declines markedly after menopause.
The defining symptom and major complaint associated with seborrhea of the scalp is excessive oiliness of the scalp and hair. A greasy-looking scalp is an unsightly and excessively oily hair is both unattractive and difficult to style. In males-young males especially-seborrhea often occurs in conjunction with acne. Seborrhea can often be managed at home by keeping the scalp clean with shampooing as often as necessary. Some over-the-counter shampoos are labeled for use on oily hair. Seborrhea that is resistant to home treatment should be referred to a physician for examination. Medical treatment may include a medication that reduces sebum synthesis. An additional examination may be necessary if an underlying hormonal dysfunction is suspected.
Seborrheic Dermatitis of the Scalp
Seborrheic Dermatitis is the condition that causes excessive oiliness. Seborrheic Dermatitis shares some features with psoriasis , and some researchers have proposed that seborrheic dermatitis and psoriasis may have some genetic predispositions in common. Other Researchers believe that the cause is a fungal infection. Excessive skin oiliness may be a predisposing factor.
Seborrheic dermatitis is seen most frequently in infants up to 3 months old (when the condition is called “cradle cap”), and in adults over age 30-40, more commonly in men than in women. It is seen frequently in persons infected with the human immunodeficiency virus (HIV), indicating that immune system dysfunction is an underlying or contributing cause of seborrheic dermatitis. An immune dysfunction is also suggested by the frequency of secondary fungal and bacterial infections.
- The symptoms and clinical features of seborrheic dermatitis of the scalp include:
- Flaking of whitish to brownish scales from the scalp, the condition commonly called dandruff (see Dandruff);
- Greasy crusts on the scalp that become greasy yellow-to-brown scales when they fall off;
- Inflamed, boggy patches underlying the crusts;
- Extension of inflammation to the ears, eyelids, eyebrows, cheeks, and nostrils; and,
- Moderate to intense pruritus (itchiness) that may lead the patient to scratch vigorously, causing injury and additional inflammation, as well as openings for secondary infection.
Mild to moderate seborrheic dermatitis may be kept in check by frequent shampooing with over-the-counter anti-dandruff shampoos. More severe disease requires medical attention appropriate to the condition; seborrheic dermatitis and psoriasis of the scalp share many features and must be differentiated before treatment.
When a diagnosis of seborrheic dermatitis is confirmed, medical treatment may include:
- Topical corticosteroids to reduce inflammation
- Shampoos containing anti-inflammatory and anti-microbial ingredients
- Topical or systemic antibiotics or anti-fungal agents
Acne of the scalp is associated with seborrhea and excessively oily skin. The severe forms of acne that may affect the scalp should be treated by a dermatologist. Severe acne lesions on the scalp may destroy hair follicles and result in patchy hair loss.
Authoritative information about the causes and treatment of acne is available at a Website of the American Academy of Dermatology:http://skincarephysicians.com/acnenet/
Pediculosis capitis, the head louse, is one of the humanity’s constant-and unwelcome-companions. It has become adapted to a narrow environmental niche-living as a parasite on the human scalp. Related forms of louse have adapted to living as parasites on the body (body louse) or on the pubic area (crab louse)
The bite of a louse is usually undetectable, but the site of the bite becomes inflamed and itchy. The most common first symptom of infestation with head lice is intense itching. Examination of the scalp will reveal red, swollen patches in the itchy areas. Examination of the hair typically reveals clusters of grayish-white louse eggs (nits) attached to the hair shafts. Further examination will usually find live adult lice.
Outbreaks of head louse infestation are most likely at sites such as schools, nursing homes and military barracks where people come into close contact. A head louse infestation does not necessarily indicate that the infested person is “dirty”, although this is a common belief. An infestation simply indicates that a person came into a situation where the transfer of lice or louse eggs could easily occur.
Once a head louse infestation has been discovered, all members of the household or community (nursing home, barracks) should be examined. Consideration may be given to treating the entire household or community with anti-louse medication. All clothing should be thoroughly washed in very hot water, or dry cleaned. All combs and brushes should be cleaned and washed in anti-louse medication. Over-the-counter anti-louse medications are available and may be adequate to bring a single infestation under control when properly used. More potent oral and topical anti-louse medications are available only by prescription.
Although not a worm at all, the fungal infection of the scalp is most recognizable by its common name of “ringworm”. Dozens of fungi are capable of infecting the scalp, the incidence of the fungi in scalp infections varying in different geographic areas and climate zones of the world.
Tinea capitis (commonly called ringworm of the scalp) is the most common fungal scalp infection seen in the United States and other temperate-zone countries. The description “ringworm of the scalp” derives from Latin root words: “tinea” is a Latin root word for “worm”, and “capitis” derives from the Latin root for “head”.
No single fungal organism is the cause of tinea capitis. A number of fungi in the broad generic categories called Microsporum and Trichophyton are the most frequent infecting organisms. The infection is easily spread from person to person by contact with hairs shed from an infected scalp, or by contact with a pillow, hat, etc., where the infecting fungi have been deposited. Because schools are a frequent site of transmission, tinea capitis has a high incidence among school children.
Three patterns of tinea capitis are identified:
Non-inflammatory, with hairs made to appear gray by their dusting of fungi, reddish patches on scalp skin, some scaling of skin around the reddish patches, and breakage of hairs just above the hair follicles;
Inflammatory, with intensely inflamed hair follicles, moist patches of intense inflammation and broken hairs, oozing pus, intense itching and pain; and,
“Black dot” tinea capitis, named for the appearance of “black dots” of infected hairs broken just above the follicles, along with large patches of inflammation.
In all forms of tinea capitis, hair that is infected and broken may be permanently lost.
Because tinea capitis may have features that also suggest seborrheic dermatitis or psoriasis, diagnosis must be confirmed by laboratory tests specific for fungal infection. After the diagnosis is confirmed, treatment may include oral anti-fungal drugs such as:
- Steroid to reduce inflammation
Note: Many organisms are moderately resistant to griseofulvin and ketoconazole, which are also difficult to use long-term. Thus, terbinafine is most commonly given orally for 2 to 4 weeks to eradicate the infection. Oral medications are required because topical creams cannot reach the base of the hair follicle deep within the scalp where infection may be present.
Hair Shaft & Follicle Conditions
Hair disorders associated with hair loss are discussed in Hair Loss and Its Causes. Hair shaft abnormalities can be attributed to both genetic are and physical or chemical damage to the hair.
All scalp hair undergoes some degree of physical and/or chemical damage in the 2 to 8 years of its growth. Physical and chemical stresses damage the cuticle (outer, protective layer) of the hair shaft.
Physical damage typically is associated with stresses such as:
- long-term braiding or corn-rowing,
- hard brushing and combing,
- permanent waving, and
- excessive exposure to ultraviolet radiation in sunlight.
Chemical damage typically is associated with:
- use of chemical straighteners,
- curling and waving chemicals, and
- excessive exposure to salt water and ultraviolet radiation (“surfer’s hair”).