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Dandruff and Seborrheic Dermatitis

Written by pharmacist  |  24. September 2001

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Whether a result of accelerated cell turnover or due to fungus, these conditions can be controlled with OTC products.

Dandruff and seborrheic dermatitis are conditions that share a common manifestation: the patient's scalp or skin produces scales. They may also share a common etiology. Many of the same nonprescription products will effectively treat both conditions.

Etiology

Abnormal Cell Turnover: Epidermis is composed of five distinct layers. The innermost layer, next to the dermis, is known as the stratum germinativum. Epidermal cells formed here gradually begin to migrate upwards to the next layers, eventually reaching the uppermost layer, the stratum corneum. By this time, they have lost their nuclei and gained keratin, a tough substance. This process ensures that outer skin can withstand the various minor environmental assaults to which it is exposed. In other words, we are encased in a layer of dead, keratinized cells that act to protect the living tissues beneath them. The time frame required for stratum germinativum cells to lose their nuclei and become optimally keratinized is 25-30 days. For the most part, normal cell shedding is not noticed, and causes no symptoms.
Proponents of the cell turnover etiology of dandruff and seborrheic dermatitis assert that, for some patients, cell turnover is accelerated. In dandruff, cell turnover is commonly 13-15 days. Seborrheic dermatitis may result from a cell turnover of only 9-10 days. The FDA OTC Review panel, in a 1982 report on dandruff and seborrheic dermatitis, stated, "The cause of dandruff has not been clearly defined, but it is known to involve an increase in the rate of epidermal turnover. This rapid transit of cells to the surface does not allow for complete keratinization of new cells."1 The FDA mentioned this etiology again in its consumer publication in 1994, although it also briefly explored the theory of an invasive fungus.2

Fungal Etiology: A great deal of research on dandruff and seborrheic dermatitis has centered on the possible causative role of fungi. In 1873, a researcher affected with seborrheic dermatitis of the beard isolated an organism that was also noticed in 1874 by a researcher named Malassez. The fungus carried the name of the latter investigator for decades, being known as Malassezia furfur.3,4 While many other names have been used for this organism, current practice is to call it by a name it was given in 1913, Pityrosporum ovale. This lipophilic yeast is known to be a normal inhabitant of human skin (follicles).

Although the fungal etiology was once widely believed, it fell into disrepute for two reasons. One is that there were no antifungals powerful enough to eradicate the condition. Another is that corticosteroid therapy seemed to produce benefit, leading to the conclusion that cell hyperproliferation might be the root cause.

At the time of the 1982 FDA OTC Review Panel Report, the view provided by the experts was: "Proponents of this [fungal] theory support the use of antimicrobials in controlling dandruff, but the Panel has concluded that there is not a definite correlation between the presence of P. ovale and the development of dandruff."1

In 1984, however, a researcher reviewed the literature, coming to the conclusion that P. ovale fulfilled all of Koch's postulates for dandruff and seborrheic dermatitis.5 Coupled with the efficacy of ketoconazole in those conditions, medical opinion has slowly begun to swing back toward the fungal etiology.

Current treatments for dandruff and seborrheic dermatitis may in fact be effective through dual antifungal approaches, if in fact the cell turnover theory has any validity.

Dandruff

Dandruff is a condition of less severity than seborrheic dermatitis. If it is left untreated, the patient will not experience any further symptoms. Although some patients may complain of a minor itching from time to time, its effects are entirely cosmetic. It does not cause or result from inflammation, and it is not allergic in origin.

Scaling of dandruff is large clumps of dry, white or gray scales that are easily visible. An examination of the scalp shows that borders are indistinct, but there are often several roundish patches from which loose cells are shed. The crown is often a prime location for cell loss.

Dandruff is uncommon in children ages 2-10, but the incidence begins to rise precipitously as patients approach puberty. From that time, dandruff incidence rises even more rapidly until patients reach their early twenties, when it begins to fall. The number of affected people drops slowly until it becomes uncommon in middle-aged patients and the elderly. There is no gender preference. As a male begins to lose hair as the result of androgenic stimulation (androgenetic alopecia), bald spots are typically dandruff-free.

Seborrheic Dermatitis

Seborrheic dermatitis is a more severe condition than dandruff. The scales appear to have an oily consistency, and borders of the affected area are indistinct. The age of onset is usually at puberty, and it is common to have pruritus associated with the condition.

Proponents of the proliferative etiology point out that cell turnover is so rapid in dandruff that some cells still retain their nuclei, and that in seborrheic dermatitis, the process is further accelerated, with a correspondingly higher ratio of cells retaining the nuclei.

Topical Minoxidil and Scalp Flaking

Although topical minoxidil (e.g., Rogaine) is used to enhance the appearance of the scalp, it may cause an unexpected effect. Alcohol in the product may dry the scalp, resulting in flaking. Then, after using topical minoxidil for several months, the patient may notice that he or she has dandruff. The pharmacist may expect to receive an inquiry from a user who has either never had dandruff or who grew out of it years ago. Company specialists stress that this is a common side effect, and that the patient may choose to discontinue the topical minoxidil for a brief period, using a moisturizing shampoo and moisturizing conditioner (e.g., Progaine). If the problem continues, the company advises discontinuing the product completely and contacting a dermatologist for advice.


Seborrheic dermatitis was long thought to result from overproduction of sebum, hence the name. Part of the reason is that the sites most often affected are those in which sebum production is heaviest, due to a greater concentration of sebaceous glands, such as the scalp, eyebrows, eyelashes, the external ear canal, behind the ears, in the nasal folds, the midchest, in the armpits, between the shoulder blades, and the pubic area and groin.6 However, later researchers have demonstrated that patients with seborrheic dermatitis do not produce more sebum than age-matched controls.

The distribution of seborrheic dermatitis lends credence to the fungal theory, in that P. ovale cannot synthesize fatty acids of C12 or longer chain lengths.4 Thus it is dependent on gaining these fatty acids from its surroundings. As it metabolizes these fats, it may cause skin damage by producing irritant metabolites.

Treatment Options

The original panel assigned to review OTC products for dandruff and seborrheic dermatitis produced a document in 1982, which was mostly affirmed (with few changes) in the final rule published by the FDA in 1991.7 Several ingredients were found to be safe and effective for self-treatment of dandruff and seborrheic dermatitis in the 1991 final rule. Salicylic acid, selenium sulfide, zinc pyrithione and coal tar are effective in treating both conditions while sulfur and ketoconzole are effective in treating dandruff only and hydrocortisone is effective for seborrheic dermatitis only. These products can treat patients aged 2 years and older except for ketoconazole, which is not to be used to treat patients under the age of 12.

Salicylic Acid 1.8%-3%: Salicylic acid is available in the form of shampoo and foam. It functions by increasing the hydration of skin. Its mechanism may be lowering of the epidermal pH, producing an inflammation that allows skin to retain water. This artificially produced maceration causes the upper layer of the epidermis to shed. The keratolytic action removes the scales of dandruff and seborrheic dermatitis.

Selenium Sulfide 1%: Selenium sulfide is highly active in inhibiting the growth of P. ovale. It is also a proven cytostatic agent, slowing the growth of both hyperproliferative and normal cells in dandruff and seborrheic dermatitis. A 0.6% micronized form of selenium sulfide is also safe and effective for dandruff.

Zinc Pyrithione: Zinc pyrithione is safe and effective for dandruff in a 0.3%-2% concentration shampoo, and for seborrheic dermatitis in a 0.95%-2% concentration shampoo.

Hydrocortisone 0.25%- 1%: Hydrocortisone cream is safe and effective for treatment of seborrheic dermatitis, but is not to be used to treat dandruff. This is because seborrheic dermatitis has an inflammatory component, while dandruff does not.

Coal Tar 0.5%-5%": Coal tar in its various forms (e.g., coal tar distillate, coal tar extract, coal tar solution) is effective for both conditions, but is perhaps not the best choice. In addition to its unpleasant odor, it can stain the skin and hair (especially if the patient's hair color is naturally light [gray or blond]) or has been artificially bleached. It also can cause folliculitis, irritant dermatitis, and allergic dermatitis. Coal tar may cause photosensitivity reactions, and patients should be cautioned to avoid sun exposure for up to 24 hours after using it. It is also potentially carcinogenic. This was demonstrated in a 1775 landmark study of chimney sweeps and their high incidence of scrotal cancer being induced by exposure to soot and coal tar. Coal tar has caused a rash of cancers in the anogenital area, leading to a precaution against application to the rectum, genital area or groin for creams, ointments and lotions. If the product is labeled for seborrheic dermatitis, the patient should be cautioned to consult a physician before use if the condition covers a large part of the body.

Sulfur 2%-5%: Sulfur, which is available in shampoo form, may function through a keratolytic action. It is approved for dandruff in a 2%-5% concentration. It may also be combined with salicylic acid for dandruff. The combination product is also a shampoo.

Ketoconazole 1%: Ketoconazole 1% shampoo was recently switched from prescription to nonprescription status. Its antifungal activity has been found to control the flaking, scaling, and itching of dandruff safely in patients over the age of 12 years. The patient is directed to use the shampoo every three to four days for up to eight weeks, then as needed to control dandruff. If the condition worsens or fails to improve in two to four weeks, the patient should see a physician. If the scalp is broken or inflamed, the patient should not use the product.

PATIENT INFORMATION
THE SCALING OF DANDRUFF
AND SEBORRHEIC DERMATITIS
The scalp, like the hands, neck and face, is often completely exposed to the elements, including snow, rain and blistering sun. In addition, it is also exposed to all types of shampoos, conditioners, dyes, sprays, hair straighteners, hair growers, and other cosmetic hair products. All of these exposures combined can take a toll on the scalp, which may respond with several types of skin conditions.

Dandruff: One of the most common skin conditions occurring on the scalp is dandruff. Scientists are not absolutely sure that dandruff has a single cause. The upper layer of the skin covering our bodies is a layer of dead cells that continually sheds into the environment. These shed cells are not usually visible. However, this is not the case with dandruff. As the upper layer of scalp sheds its scales, the scales are visible as whitish or grayish clumps of material falling from the scalp. Scales are even more noticeable when the patient is wearing dark clothing.

Seborrheic Dermatitis: Seborrheic dermatitis (SD) is a skin condition that causes flaking and redness. It is found most often on the hairline, face, forehead, eyebrows, eyelashes, eyelids, external ear canal, and in the nasal folds. The scales are yellow and oily, rather than dry and white like dandruff.

Treatment Options: Dandruff is not harmful, and it does not lead to more serious conditions. Further, there are several types of products that may be effective in its treatment. SD is somewhat harder to treat than dandruff, but many of the products used to treat dandruff may be used to treat SD as well. Ingredients that are effective in treating both conditions include salicylic acid (Scalpicin, T/Sal), selenium sulfide (Head & Shoulders Intensive Treatment, Selsun Blue), and zinc pyrithione (Head & Shoulders). While coal tar and its various forms (Denorex, Oxipor VHC, Pentrax, Tegrin, MG217 Medicated Tar Shampoo) are effective for dandruff and SD, there are several reasons they may not be the best choice. Products containing coal tar have a characteristic odor reminiscent of road tar, which people may find unpleasant. Users of coal tar dandruff shampoos also must be cautious in exposing the skin to sunlight after use, since coal tar can increase the tendency to sunburn for up to 24 hours after use. Unlike milder treatments, it should not be used for prolonged periods without consulting a physician.

Sulfur (Suave Dandruff Control Shampoo) and salicylic acid combined with sulfur (MG217 Medicated Tar-Free Shampoo) are effective in treating dandruff only. There is also a new dandruff treatment: Nizoral A-D shampoo. Based on the finding that some people with dandruff have a fungus living on the scalp that causes the scaling, Nizoral A-D contains an antifungal ingredient known as ketoconazole. It can control the flaking, scaling, and itching associated with dandruff. It should not be used on children under the age of 12 years.

Hydrocortisone cream (Cortaid, Scalpicin) may be used to treat SD only. If seborrheic dermatitis covers a large part of the body, it is advisable to seek the advice of a physician before applying this or any other nonprescription product.


Remember, if you have questions, Consult Your Pharmacist.

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