What is the recommended management for pityriasis capitis?

Management of Pityriasis Capitis (Dandruff)

For pityriasis capitis (dandruff), use medicated shampoos containing antifungal agents such as ketoconazole 2%, zinc pyrithione 1%, or piroctone olamine 0.75% with salicylic acid 2%, applied 2-3 times weekly for 4 weeks, as this condition is primarily managed with topical therapy rather than systemic antifungals. 1, 2, 3

Important Distinction: Pityriasis Capitis vs. Tinea Capitis

It is critical to differentiate pityriasis capitis (dandruff) from tinea capitis (scalp ringworm), as they require completely different management approaches:

• Pityriasis capitis is a chronic scaling condition associated with Malassezia yeast overgrowth and responds to topical antifungal shampoos alone 1, 3
• Tinea capitis is a dermatophyte infection requiring systemic oral antifungal therapy, as topical therapy alone cannot eradicate the infection 4

First-Line Topical Treatment Options

Ketoconazole 2% Shampoo

• Apply 2-3 times weekly for 4 weeks 3
• Highly effective against Malassezia species (both M. furfur and M. globosa) 3
• Clinical effectiveness of 92% with mycological effectiveness of 69% demonstrated in controlled trials 3
• Can be used as monotherapy for pityriasis capitis 3

Zinc Pyrithione 1% Shampoo

• Apply 2-3 times weekly for 4 weeks 1, 2
• Conventional anti-dandruff agent with proven efficacy 2
• Marked decrease in scaling, seborrhea, erythema, burning, and itching after 4 weeks of treatment 2

Piroctone Olamine 0.75% + Salicylic Acid 2% Combination

• Apply twice weekly for 4 weeks 1
• Slightly more effective than zinc pyrithione in reducing severity and area affected by scaling 1
• The salicylic acid component provides keratolytic action to help remove scales 1

Treatment Algorithm

1. Confirm diagnosis clinically: Look for diffuse fine white scaling of the scalp without significant hair loss or inflammatory changes
2. Select appropriate medicated shampoo: Choose from ketoconazole 2%, zinc pyrithione 1%, or piroctone olamine/salicylic acid combination based on availability and patient preference 1, 2, 3
3. Application technique: Leave shampoo on scalp for 3-5 minutes before rinsing to allow adequate contact time
4. Treatment duration: Continue for minimum 4 weeks with 2-3 applications per week 1, 2, 3
5. Maintenance therapy: After initial clearance, continue once-weekly applications to prevent recurrence

Expected Response Timeline

• Symptom relief: Patients typically report absence of pruritus within 2-6 days of starting treatment 5
• Clinical improvement: Marked reduction in scaling and other signs visible within 2 weeks 2, 5
• Complete clearance: Achieved by 4 weeks in most cases 1, 2, 3

Common Pitfalls to Avoid

• Do not prescribe oral antifungals: Pityriasis capitis responds to topical therapy alone; systemic antifungals are unnecessary and expose patients to potential hepatotoxicity risk 6
• Avoid inadequate contact time: Ensure patients leave medicated shampoo on scalp for several minutes rather than immediately rinsing 1
• Do not discontinue too early: Complete the full 4-week course even if symptoms resolve earlier to prevent rapid recurrence 1, 2
• Rule out tinea capitis: If you see focal alopecia, kerion, lymphadenopathy, or broken hairs, obtain fungal culture as this indicates tinea capitis requiring systemic therapy 4

Maintenance and Prevention

• Continue once-weekly medicated shampoo applications long-term to prevent recurrence 1
• Address contributing factors such as seborrheic dermatitis if present
• No need for family screening or environmental decontamination, as pityriasis capitis is not contagious like tinea capitis 6