First-Line Treatment for Dandruff (Scalp Seborrheic Dermatitis)
Ketoconazole 2% shampoo applied twice weekly for 2-4 weeks is the first-line treatment for dandruff, achieving an 88% excellent response rate and providing superior long-term control when continued weekly as maintenance therapy. 1, 2
Core Treatment Algorithm
Initial Treatment Phase (2-4 Weeks)
Apply ketoconazole 2% shampoo twice weekly by placing 5 mL directly onto the scalp skin (not just the hair), leaving it on for 3-5 minutes before rinsing to allow adequate contact time with the scalp surface 1, 2
For significant inflammation or itching during active flares, add hydrocortisone 1% cream applied once or twice daily for short periods only (days to 1-2 weeks maximum) to reduce erythema while minimizing risk of skin atrophy 1, 3
Alternative first-line antifungal options include selenium sulfide 1% shampoo (applied twice weekly initially, then at less frequent intervals as needed), ciclopirox 1% shampoo (twice weekly), or pyrithione zinc shampoo 4, 3, 5, 6
Maintenance Phase (After Initial Clearing)
Continue ketoconazole 2% shampoo once weekly indefinitely as prophylactic maintenance, which reduces relapse rates from 47% (placebo) to 19% (active treatment), significantly preventing recurrence compared to reactive treatment only 1, 2
Selenium sulfide may be used weekly, every 2 weeks, or every 3-4 weeks depending on individual response, but should not be applied more frequently than required to maintain control 4
Essential Supportive Skin Care Measures
Use mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes to preserve the skin's natural lipid barrier, as regular soaps and detergents strip natural lipids and worsen the condition 3, 1
Apply fragrance-free emollients after bathing to damp skin to create a surface lipid film that prevents transepidermal water loss 3
Avoid all alcohol-containing preparations, perfumes, and deodorants on affected areas, as these significantly worsen dryness and can trigger flares 3, 1
Critical Pitfalls to Avoid
Do not use potent or medium-potency topical corticosteroids on the scalp or face due to high risk of skin atrophy, telangiectasia, and tachyphylaxis; limit any corticosteroid use to low-potency options (hydrocortisone 1%) for short periods only 3, 1
Ensure proper shampoo application technique by applying directly to the scalp skin rather than allowing it to remain only on hair shafts, which is a common reason for treatment failure 1
Avoid undertreatment due to "steroid phobia" when short-term low-potency corticosteroids are indicated for significant inflammation 3
Do not continue ineffective treatment indefinitely; if no improvement occurs after 4-6 weeks of appropriate ketoconazole 2% treatment, refer to dermatology for diagnostic uncertainty or consideration of second-line therapies 3, 1
When to Refer to Dermatology
Referral is indicated for: 3, 1
- Failure to respond after 4-6 weeks of appropriate first-line therapy
- Diagnostic uncertainty or atypical presentation
- Recurrent severe flares despite optimal maintenance therapy
- Need for second-line treatments such as topical calcineurin inhibitors or phototherapy