From the FDA Drug Label
For treatment of dandruff and seborrheic dermatitis: Usually two applications each week for two weeks will afford control. INDICATIONS AND USAGE: For treatment of tinea versicolor, seborrheic dermatitis of scalp and treatment of dandruff.
The treatment for dandruff includes using selenium sulfide (TOP) lotion, with the usual application being two times a week for two weeks to achieve control. After this initial period, the lotion can be used at less frequent intervals, such as weekly, every two weeks, or every 3 or 4 weeks, as needed to maintain control 1.
- Key points:
- Apply selenium sulfide (TOP) lotion two times a week for two weeks
- Use at less frequent intervals after initial control is achieved
- Contraindications: patients allergic to any of its ingredients 1
- Precautions: not to be used when acute inflammation or exudation is present, as increased absorption may occur 1
From the Research
For refractory dandruff, the most effective treatment is a medicated shampoo containing ketoconazole 2%, used 2-3 times weekly for at least 4 weeks, as it has been shown to be superior to other treatments in reducing dandruff severity and preventing recurrence 2, 3.
Treatment Approach
The treatment of refractory dandruff should start with a medicated shampoo containing ketoconazole 2%, such as Nizoral, used 2-3 times weekly for at least 4 weeks. It is essential to leave the shampoo on the scalp for 3-5 minutes before rinsing to allow for optimal absorption and effect.
Alternatives and Adjuncts
If the initial treatment does not provide adequate relief, alternatives or adjuncts can be considered, including:
- Selenium sulfide shampoo (like Selsun Blue 2.5%)
- Zinc pyrithione shampoo (Head & Shoulders Clinical Strength 1%)
- Prescription-strength options like fluconazole shampoo or topical corticosteroid solutions (e.g., clobetasol 0.05%) applied directly to the scalp once daily for 1-2 weeks
- Oral antifungals such as fluconazole 150mg weekly for 2-4 weeks in extremely resistant cases
Maintenance and Prevention
Maintaining the treatment regimen even after symptoms improve is crucial to prevent recurrence. Gradually tapering to a maintenance schedule of medicated shampoo 1-2 times weekly is advised. This approach helps in managing the condition and reducing the risk of future flare-ups.
Evidence Support
The recommendation for ketoconazole 2% shampoo is supported by studies that demonstrate its efficacy in reducing dandruff severity and preventing recurrence 2, 3. Additionally, a more recent study highlights the effectiveness of ketoconazole and zinc pyrithione shampoos against Malassezia spp. and Staphylococcus spp. 4, further supporting the use of these agents in the treatment of refractory dandruff.