Symptoms and Treatment of Pityriasis Capitis (Dandruff)
Clinical Presentation
Pityriasis capitis (dandruff) presents as generalized, diffuse scaling of the scalp with flakes visible in the hair, often accompanied by itching, and occasionally redness or burning sensations. 1, 2, 3
Primary Symptoms
- Scaling: White or grayish flakes shed from the scalp, ranging from mild fine scaling (similar to dry skin) to severe thick scaling 2, 3, 4
- Pruritus: Itching of the scalp is a common accompanying symptom 2, 3
- Erythema: Redness may be present in some cases 5
- Seborrhea: Increased oiliness of the scalp may accompany the scaling 5
- Burning sensation: Some patients report a burning feeling on the scalp 5
Important Clinical Distinctions
Dandruff can be difficult to distinguish from mild tinea capitis (fungal scalp infection), as both present with scaling, but dandruff typically does not cause significant hair loss, which helps differentiate it from fungal infections 1. The condition affects up to 50% of the population at some point in their lives, with greatest prevalence and severity in young men 3.
Treatment Approach
First-Line Topical Therapy
Antifungal shampoos should be the primary treatment for dandruff, as they target the causative Malassezia yeast and provide longer remission compared to corticosteroids. 6
FDA-Approved Selenium Sulfide Regimen
- Initial treatment: Apply selenium sulfide 2.5% shampoo twice weekly for 2 weeks 7
- Application technique: Massage 1-2 teaspoonfuls into wet scalp, allow to remain for 2-3 minutes, rinse thoroughly, then repeat application and rinse again 7
- Maintenance: After initial control, reduce frequency to weekly, every 2 weeks, or every 3-4 weeks as needed to maintain control 7
- Mechanism: Selenium sulfide has a cytostatic effect on epidermal cells, reducing corneocyte production 7
Alternative Antifungal Shampoos
- Zinc pyrithione (1%): Effective antifungal option that can be used twice weekly 2, 3
- Ketoconazole shampoo: Reduces Malassezia scalp reservoirs 6, 3
- Piroctone olamine (0.75%) combined with salicylic acid (2%): May be slightly more effective than zinc pyrithione in reducing severity and affected area 2
- Ciclopirox olamine: Another effective antifungal option 6, 3
Adjunctive Keratolytic Agents
For thick scaling, consider alternating or combining antifungals with keratolytic agents 3:
- Salicylic acid: Helps soften thick scalp plaques; overnight occlusion with salicylic acid oil may be beneficial for severe cases 3
- Tar, sulfur, or urea: Can be alternated with antifungal shampoos 3
Treatment Duration and Technique
- Lathering time: Longer periods of lathering improve efficacy; everyday shampooing may be needed initially 3
- Expected timeline: Marked decrease in signs and symptoms typically occurs within 4 weeks of twice-weekly treatment 2, 5
Important Clinical Caveats
Contraindications and Precautions
- Avoid selenium sulfide when acute inflammation or exudation is present, as increased absorption may occur 7
- Pregnancy: Selenium sulfide is Category C; should not ordinarily be used in pregnant women 7
- Pediatric use: Safety and effectiveness in infants have not been established 7
- Jewelry: Remove before application as selenium sulfide may damage jewelry 7
Common Pitfalls
- Hair care products: Discontinue hair spray and pomades/gels during treatment, as they can aggravate the condition 3
- Inadequate rinsing: Thorough rinsing after treatment is essential to avoid hair discoloration 7
- Premature discontinuation: The condition commonly recurs, so maintenance therapy is mandatory to prevent relapse 6
Adverse Effects to Monitor
- Skin irritation (most common) 7
- Occasional increase in normal hair loss 7
- Hair discoloration (minimized by thorough rinsing) 7
- Oiliness or dryness of hair and scalp 7