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Clinician’s Corner: Dandruff


Cause: We are familiar with the appearance of dandruff, which the scalp shows fine, white, diffuse scaliness. The rate of turnover of the skin cells is about twice the normal rate in patients affected with dandruff.

Malassezia (formerly called Pityrosporum) is a “oil dependent” fungus (yeast) that lives on the scalps of most healthy patients. Sometimes it grows out of control, feeding on the oils secreted by hair follicles and causing irritation that leads to increased cell turnover. The result is many dead skin cells, which fall off, clump together with oil from hair and scalp, and become visible.  Unfortunately, they end up on our black tuxedos or cocktail dresses!

Factors influencing overgrowth:  increased oil production; hormonal fluctuations; stress; illness; neurological disorders such as Parkinson’s disease; a suppressed immune system; infrequent shampooing and extra sensitivity to the malassezia fungus may contribute to the development of dandruff.

Treatment : The 2017 Sanford Guide recommends two first line treatments for dandruff:    ketoconazole 2% or selenium sulfide 2.5%

Nizoral® Ketoconazole 2% Shampoo(Rx) only:

  • Mechanism: Ketoconazole weakens the fungal cell membrane.
  • Dosage: Apply twice a week. Leave on for 5 minutes and thoroughly rinse.
  • Patient Care points: immediate lather hair when starting shower, to let ketoconazole saturate the hair and scalp for 5 minutes to get full benefit. Nizoral® A/D shampoo 1% is the over the counter version.

Selenium Sulfide 2.5% (lotion/shampoo)

  • Mechanism: controls dandruff via its anti-fungal effect and significantly reduces the rate of cell turnover.
  • Dosage: usually applied twice a week. Thoroughly rinse.
  • Patient care points: Remove jewelry to prevent staining from sulfide.  Although this is the most effective treatment for dandruff, the sulfide (“rotten egg”) smell steers patients away from this drug. Selsun Blue 1%   is the over the counter version.

Head and Shoulders® Zinc pyrithione (ZPT)

  • Mechanism: Heals the scalp normalizing rate of cell growth, oil production, or both. Also shown to significantly reduce the numbers of yeast organisms.
  • Dosage: Is effective if used three times a week.
  • Patient care points: Don’t alternate between ZPT and non-medicated shampoos. Use only ZPT containing product if using every day.

Neutrogena T/gelCoal tar based .5%

  • Mechanism: reduces rate of skin cell formation, and also softens keratin; also elicits antiseptic & antibacterial properties
  • Dosage: best if used twice a week.
  • Patient care points: Use caution in exposing scalp to sunlight after applying this product. It may increase your tendency to sunburn for up to 24 hours after application. Does smell like a freshly paved road. 

Your Thompson Pharmacist is a great resource for treatment of dandruff.  We have a lot of great products that don’t require a prescription for managing your dandruff. Go ahead and ask… at Thompson Pharmacy it’s all for YOU!