Scaly Flakes on Scalp in Menopause
The most likely diagnosis is seborrheic dermatitis, and first-line treatment is ketoconazole 2% shampoo twice weekly for 2-4 weeks, followed by once-weekly maintenance therapy. 1
Primary Diagnosis
Scaly flakes on the scalp in a postmenopausal woman most commonly represents seborrheic dermatitis (dandruff), which affects over 50% of adults and is characterized by powdery or greasy scale along hair margins and skin folds. 2, 3 The condition results from three converging factors: sebaceous gland secretions, Malassezia yeast metabolism (particularly M. restricta and M. globosa), and individual susceptibility. 3
Treatment Algorithm
First-Line Therapy
- Start with ketoconazole 2% shampoo applied twice weekly for 2-4 weeks, which produces an excellent response in 88% of patients with moderate to severe seborrheic dermatitis. 1
- After initial clearance, transition to once-weekly maintenance therapy with ketoconazole 2% shampoo to prevent relapse—this reduces recurrence to 19% compared to 47% with placebo. 1
Alternative First-Line Options
- Selenium sulfide shampoo, pyrithione zinc shampoo, or topical ketoconazole cream can be used if ketoconazole shampoo is unavailable. 2
- These antifungal agents target the Malassezia yeast that drives the inflammatory process. 3
Second-Line Therapy for Resistant Cases
- Clobetasol propionate shampoo 0.05% applied for 5-10 minutes twice weekly provides superior efficacy compared to vehicle and is safe for short-contact application. 4
- Topical corticosteroids address the inflammatory component when antifungals alone are insufficient. 2
Important Differential Consideration
While seborrheic dermatitis is most likely, consider evaluating for hair loss if the patient reports thinning, as postmenopausal women commonly experience androgenetic alopecia affecting over 50% of this population. 5 However, androgenetic alopecia presents with diffuse crown thinning rather than scalp flaking. 5
If hair loss accompanies the scaling, check:
- TSH and free T4 (thyroid dysfunction) 5
- Serum ferritin (iron deficiency causes chronic telogen hair loss) 5
- Vitamin D levels (70% of women with hair loss are deficient) 5
- Serum zinc (cofactor for hair follicle function) 5
Critical Pitfalls to Avoid
- Do not confuse seborrheic dermatitis with psoriasis—psoriasis presents with thick plaques covered by micaceous (silvery) scales rather than the powdery/greasy flakes of seborrheic dermatitis. 6
- Do not assume all scalp scaling is benign—if patches of hair loss accompany the scaling, consider alopecia areata (look for exclamation mark hairs on dermoscopy) or tinea capitis (requires fungal culture). 7
- Maintain long-term prophylaxis—seborrheic dermatitis is chronic and requires ongoing once-weekly ketoconazole shampoo to prevent relapse. 1
Hormonal Context in Menopause
Postmenopausal women may experience endocrine therapy-induced alopecia if taking aromatase inhibitors, which presents as grade 1 alopecia primarily on the crown (not flaking). 6 However, the primary complaint of scaly flakes points to seborrheic dermatitis rather than hormonal hair loss. 2, 3