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Dandruff and seborrheic dermatitis both seem to result from a reaction to yeast that normally live on the skin. You CAN control Malassezia!

Dandruff may be dastardly, but in general, it is not a serious medical condition. Though people who have it may be frustrated by it, or even desperate for relief, dermatologists don’t get too excited when they see it. The flakes are not life threatening. They never require surgery. They are not contagious and, unlike flatulence, they don’t drive others away. But a bad case of dandruff makes people self-conscious, and thanks to decades of advertising, may even carry a social stigma. The good news is that there are a surprising number of successful strategies to control or even overcome dandruff.

What Is Dandruff?

Skin cells die and are sloughed off every day, all over the body. But on the scalp, they may clump together and form flakes that stick in the hair or fall to the shoulders. They are readily visible on a dark shirt or sweater.

If the flakes are especially large and numerous and the scalp is particularly itchy and red, a dermatologist might identify the problem as seborrheic dermatitis. This condition may also affect the face. In some people, patches of skin on the forehead (including the eyebrows), the sides of the nose, and the chin seem to be especially susceptible to developing reddish, itchy scales.

This reader overcame a decades-long flake problem with Nizoral shampoo:

“I fought dandruff for 30 years. Even my eyebrows itched. I only bought light-colored clothing that wouldn’t show flakes.

My dermatologist recommended various shampoos that didn’t work. When I changed doctors, my new doctor said my “dandruff” was a yeast infection. She recommended Nizoral shampoo. I only have to use it about once a month and I have no more flakes or itching.

I know this story isn’t as dramatic as finding a cure for cancer, but solving an annoyance like this is truly liberating.”

The Yeastie Beasties:

You have no doubt heard about the microbiome of the digestive tract. These are the microorganisms (bacteria, viruses and fungi) that populate our large intestines. Well, there is also a microbiome of the skin.

Dermatologists usually distinguish between dandruff and seborrheic dermatitis, but researchers now believe that both conditions can be traced to the skin’s reaction to yeast that lives on its surface (Journal of Clinical and Investigative Dermatology, Dec. 2015). This fungus, Malassezia globo and related species, sets up housekeeping, especially where the skin is secreting oils.

The fungus then produces oils of its own, which irritate the skin. The resulting reaction is the excessive flaking typical of dandruff or the redness and itching on the scalp and face that characterize seborrheic dermatitis. Presumably, the big difference between dandruff and seborrheic dermatitis is the amount of irritation/inflammation that results.

Dandruff vs. Seborrheic Dermatitis:

Dandruff is generally restricted to the scalp and is defined as itchy, flaky skin. Seborrheic dermatitis (SD) also involves itching and flaking but has inflammation as an added insult. SD can affect the scalp but the inflammation can also be found around eyelids, eyebrows, ears, the creases near the nose and mouth. Sometimes the chest can also be involved.

Malassezia yeasts normally inhabit the skin. We do not understand  why some people are more irritated by Malassezia by-products than others. It might have something to do with hormones, or diet, or the activity of the immune system. In other words, the state of our skin could make it easier or harder for the yeast to flourish or flounder.

Because dermatologists don’t know how to change individual susceptibility, the basic approach has been just to kill off as many of the yeastie beasties as is practical without hurting the scalp. This not only makes sense, it actually works most of the time. And it also explains why some dandruff shampoos seem to lose effectiveness over time. Presumably, the yeast can develop resistance.

Fighting Fungus:

Once in awhile, people taking an oral antifungal drug for another problem report that it gets rid of their dandruff. But even for super-dandruff (aka seborrheic dermatitis of the scalp), an oral antifungal is too big a cannon to consider seriously. Why risk potentially serious side effects over dandruff?

Dandruff and seborrheic dermatitis both seem to result from a reaction to yeast that normally live on the skin. Scientists don’t know why some people react while others do not, nor are they sure why Malassezia yeasts seem to grow more vigorously on some people’s skin than on others’. But research has shown that making life hard for the yeast usually controls the flaking and itching that are so bothersome.

The Antifungal Drug Ketoconazole (Nizoral A-F) Is Now OTC!

Readers often report on successful strategies they employ. Here is one involving the topical antifungal drug ketoconazole:

Q. I am a big fan of Nizoral shampoo. It used to only be available by prescription. Now I can buy it over the counter. What’s the difference?

I don’t just use Nizoral for dandruff. I also use it as a body wash–on my face, behind my ears and between my toes. I leave it on for about two to three minutes and then rinse it off. I find it gets rid of my dandruff and itchy, flaky skin. Nizoral also seems to help with my athlete’s foot problem.

A. A 2% formulation of Nizoral (ketoconazole) was approved by the FDA in 1990 to control:

“flaking, scaling and itching associated with dandruff.”

This antifungal shampoo required a doctor’s prescription.

In 1997 the FDA permitted over-the-counter sale of a lower-strength (1%) formulation called Nizoral A-D (Anti-Dandruff) Shampoo. Even at this reduced concentration the anti-fungal ingredient, ketoconazole, is quite effective. It can discourage yeast growth on the scalp and skin.

Some dermatologists prescribe the 2% shampoo to treat jock itch (tinea cruris) and ringworm (tinea corporis). It can also help control another fungal infection called tinea versicolor that causes discolored skin patches.

Home Remedies for Dandruff:

Readers have suggested a range of self-treatments for dandruff. Remember, if any of these remedies makes matters worse, stop it right away and give your skin time to recover before you try anything else. When in doubt, check with a dermatologist!

  • Drench the scalp with Listerine original (amber) mouthwash before shampooing. The herbal oils and alcohol in Listerine discourage the growth of yeast on the scalp.
  • Smear some Vicks VapoRub on itchy, red, scaly spots. It contains many of the same antifungal herbal oils as Listerine. It can be very difficult to remove Vicks from hair, though.
  • Brew some herbal tea with sage or rosemary. Use it as a rinse after shampooing your hair.
  • Slather yogurt containing live cultures on the scalp. Leave it for 15 minutes before shampooing it out. Unlike the petrolatum in Vicks VapoRub, yogurt should be fairly easy to wash out.
  • Make a rinse with vinegar diluted at least two to one in water. Some people prefer apple cider vinegar, while others use the cheapest white vinegar.
  • Switch from one type of dandruff shampoo to another every 6 to 8 weeks. Don’t give Malassezia a chance to adapt.
  • Try using Nizoral A-D shampoo twice a week, then cut back and use it only as often as needed to keep flaking under control.
  • If none of this helps, check with your doctor. Perhaps your condition is not ordinary dandruff.
  • A prescription shampoo such as Loprox may help when other measures have failed.

Free Information About Hair and Nail Problems:

To learn more about other effective dandruff control strategies and ways to deal with hair loss, you may wish to download our free eGuide to Hair and Nail Care. This resource is available under the Health eGuides tab.

What have you used to control dandruff or seborrheic dermatitis? Please share your story in the comment section below.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.”.
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