Oh the joys of dandruff. Tiny little flakes resting upon the shoulders of your favorite sweater. The constant discomfort from itching that leads to uncontrollable scratching. Dandruff is simply a lay term referring to all the flaking that takes place on the scalp. However, most cases of dandruff are really due to a genetic condition known as seborrheic dermatitis, aka seborrhea. But do not fear, you too can keep unwanted flaking at bay and have a beautiful healthy scalp (not to mention hair) if you can learn to understand there is a method to the madness of keeping dandruff under control.

What's It All About?

You would be amazed that the majority of people mistakenly think that dandruff is due to having a bad case of dry skin on the scalp (or face). Seborrhea is actually a hereditary problem where the skin begins to be produced too quickly. I often explain dandruff as thinking of it as having a "short circuit" in the way the skin is being made. Periodically, and usually unpredictably, the skin in affected areas starts reproducing itself faster than normal. When this happens, the extra skin cannot be shed innocuously, (we shed skin cells daily but in such small amounts it typically goes unnoticed) so the flakes appear.

Dandruff due to seborrhea starts anytime after people hit puberty. Part of the reason for this is the involvement of the sebaceous sweat glands in seborrhea which cannot function until hormones secreted during puberty appear. The sweat glands go into overdrive and produce sebum that contributes to the "greasy" texture of dandruff.

Sebaceous glands go hand in hand with hair follicles. While we most commonly think of dandruff affecting the scalp and beard areas (for men), the eyebrows, nasolabial folds and occasionally the chest, back and legs (mostly a male concern) may be prone to developing dandruff. Seborrhea only occurs in areas that grow hair.

Inflammation often accompanies dandruff, leading to itching. The length of time that the dandruff is active and rate of recurrence is going to vary for every individual. Patients often find the sheer unpredictability maddening.

Here We Go Again...

There are definitely trigger factors to seborrhea. Seasonal changes (especially winter weather) are a common stimulus. So, too, are illness, stress, infections, hormonal imbalances, and neurological conditions (such as paralysis, Alzheimers, and stroke). Unfortunately, there is nothing you can do to alter these life events. And since seborrhea is programmed into you, you should consider it highly controllable instead of curable.

Got Dandruff?

Dandruff, particularly seborrhea is not a mono therapy kind of skin concern. Take advantage of the myriad of available options using different active ingredients to seize control of this annoying condition. Treatment ranges from OTC shampoos to rx items. Active ingredients used in dandruff treatment include:

• Zinc Pyrithione
• Salicylic Acid
• Ketoconazole (Nizoral)
• Glycolic Acid
• Steroids
• Sulfur
• Tar (Ionil-T Shampoo)

Different ingredients have different actions. Zinc pyrithione in DHS Zinc Shampoo helps normalize the formation of the epithelial skin. Glycolic acid in Aqua Glycolic Shampoo & Body Cleanser while sulfur helps remove excess flaking. The addition of salicyclic acid (as in Meted Anti-Dandruff Shampoo)works to exfoliate scales and reduce flaking.

A special mention goes to P&S Liquid. Think of it as a masque for your scalp. While it doesn't peel off the way a facial masque does, applying P&S Liquid to the scalp at night and wash it out in the morning is heaven sent for anyone with severe scaling of the scalp. You will probably only need to do this nightly for about 3 nights and then use it on a periodic maintenance basis when recurrences aren't responsive to your other treatments. DS Laboratories Dandrene High Performance Antidandruff Shampoo is another great option and can be used 3-4 times weekly to efficiently remove dead cells from scalp skin.

There's no question that dandruff shampoos may be somewhat harsh on your hair. They don't however, stain your hair the way tar shampoos may. I have found that DHS Conditioning Rinse is a very good choice for helping restore the moisture to the hair after using a dandruff shampoo. I was diagnosed with seborrhea myself while in college, and have personally gone through innumerable bottles of DHS Zinc Shampoo and DHS Conditioning Rinse.

When all else fails, it is time to see the dermatologist. What would be your best bets for therapy? I have found that seborrhea responds better to a "cocktail" of sorts of various therapeutic agents. The different products have different modes of intervention in treating seborrhea, so that is why interrupting the physiology of the condition at multiple points is more successful. Nizoral 2% shampoo works because it reduces the amounts of bacteria and yeast that live on our skin, stimulating the seborrhea. Using this shampoo twice weekly is highly effective WHEN COMBINED WITH OTHER TREATMENT. There aren't too many of my patients who ever responded to it alone - you need something to bolster it's actions.

Capex, a prescription steroid-based shampoo formally called FS shampoo, is also something I rely upon for treating stubborn cases of dandruff. The steroid helps diminish the inflammation that accompanies the process. Shampoo daily for a week with Capex, and then use it 1-2 times a week thereafter, alternating with their prescription version of Nizoral shampoo, and DHS shampoo.

At the height of the flare, topical steroid drops are needed. Packaged in "Visine-like" bottles, just 5-8 drops are randomly scattered on the scalp twice a day when shampoos simply aren't enough to control the situation. When the dandruff subsides, the drops are shelved until the next bout. These steroid solutions vary widely in their strength, and I base my selection upon how severe the condition is. Over the counter steroid solutions options are fairly unavailable. But that's where DERMAdoctor Handy Manum Medicated Skin Repair Serum with 1% Hydrocortisone can come to the rescue. The one percent hydrocortisone helps soothe itching and inflammation while the hydrating dry oil base softens dry, flaking skin. Apply small dabs directly to the scalp-skip the hair. Try it at bedtime. You can choose to place a towel on your pillow case or even wear a shower cap to protect linens and provide a more even, deep penetration.

African Americans who suffer from seborrhea are often more in a quandary of how to handle their scalp care due to styling limitations. Shampooing daily is out of the question for all but the worst conditions. I urge these patients to shampoo weekly with the dandruff shampoo we have agreed upon, and instead, will rely upon daily applications of medicated solutions or oils to control the dandruff. As oils are often used for styling purposes, a prescription steroid based oil, called DermaSmooth FS oil, (or OTC DERMAdoctor Handy Manum Medicated Skin Repair Serum with 1% Hydrocortisone) is often integrated into a daily routine. Or, a topical steroid solution may be applied twice a day.

Zinc pyrithione may be one way to help avoid or reduce topical steroid use during dandruff flare-ups. DermaZinc - Advanced Formula Zinc Therapy Spray/Drops can be applied to the scalp in lieu of, or in addition to your steroid solution or oil. Weaning off the topical steroid and using DermaZinc - Advanced Formula Zinc Therapy Spray/Drops on a maintenance or as needed basis can go a long way to keeping itching and flaking at bay.

Dandruff On My Face?!

Although most people are familiar with dandruff, they are usually unaware that this can also occur on the face, including the eyebrows, globella (the portion of the forehead between the brows), the nasolabial folds (the creases that extend from the nose to the angles of the mouth), and for men, the beard area as well. Enter DERMAdoctor Born To Be Mild Medicated Face & Body Cleanser. The first cleanser of its kind to effectively treat the symptoms of seborrheic dermatitis AND be gentle without causing a worsening of irritation, dryness or redness.

Remember that dandruff is unpredictable. This year's scalp condition may be next year's facial concern. After more than 20 years of personally dealing with seborrhea of the scalp, I have just found flakes peeking out from my eyebrows. This is definitely a "go-with-the-flow" type of skin condition. If you take a more relaxed approach not only will you be happier, but the reduced stress will be good for your dandruff, too.

Mirror Mirror On The Wall, Who's The Fairest Of Them All?
... Or, Clear My Face Fast!

For the face, I will usually use a prescription steroid lotion, such as Desowen lotion twice daily. At times, I will have the patient also use prescription Nizoral cream (they make Nizoral in lots of ways!) along with it. They can be applied at the same time, and in fact I usually suggest that a small dab of both be mixed together for easier application. For men with beards, washing their face with the dandruff shampoo is very helpful. Of course, all of these products need to be kept out of the eyes. One of my favorite "old-fashioned" prescription formulations includes 3% precipitated sulfur mixed with a mild topical steroid cream. It does seem to work well for seborrhea on the face or chest that has not responded to other treatment options.

Ovace, a newly approved prescription cleanser for the treatment of facial seborrheic dermatitis (aka seborrhea or dandruff) is a sulfa based wash which contains 10% sodium sulfacetamide. It is used once a day and comes in 2 sizes, 6 and 12 oz bottles.

OTC Solutions For Clearing Facial Dandruff

• Wash your face once daily with ZNP Bar. This bar works very well but can be drying particularly during the dry winter months when you are most likely to develop facial dandruff.
• Cortaid Advanced Maximum Strength Cream mixed with equal parts DERMAdoctor Feet Accompli Ultimate Antifungal Pedicure Cream apply to the affected area twice daily. Once you are clear, try backing off slowly from the Cortaid Advanced Maximum Strength Cream over a week or two and relying upon the DERMAdoctor Feet Accompli Ultimate Antifungal Pedicure Cream. The latter contains a potent antiyeast/antifungal agent yet the base is elegant and absolutely ideal for use on the face (it's even non-comedogenic!). If you stay clear, then slowly over another week or two try to eliminate the use of DERMAdoctor Feet Accompli Ultimate Antifungal Pedicure Cream, too.
• If you want to try to recreate the concept of using sulfur mixed with steroid cream, consider mixing equal parts of Cortaid Advanced Maximum Strength Cream with Rezamid Acne Treatment Lotion. I would start out just once daily and if you do not experience unwanted dryness, then advance to twice daily. Rezamid Acne Treatment Lotion contains resorcinol, a drying agent so you want to be careful that you do not overly dry out your skin.
• Finally, zinc pyrithione can be found in a cream form, DermaZinc Cream. Use it alone or with an occasional dab of Cortaid Advanced Maximum Strength Cream to soothe facial flaking.

It is important to remember that seborrhea is controllable not curable. Every individual experiences their own pattern (or lack thereof) of dandruff recurrences. Your best strategy for managing dandruff is to stay away from steroid based treatments whenever possible. Simply shelve them when your condition is clear and see how your other medicated products handle the situation. If you are able to hold off on all of your treatments, have them on hand when you feel the need to restart. Early intervention when the earliest itching is felt, or the mildest of scaling is noted helps cut down on overwhelming flaking.

For others, continuous use of medicated shampoos, creams and lotions may be all that keeps you from having ongoing flaking and itching. It is always fine to try to stop your seborrhea products when you are fully clear and take a wait-and-see approach. You can always restart them when the time is right.

Thank you for taking the time to read through this important information. I hope you have found this article informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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