Scaly Scalp Treatment: A Dermatologist’s Tips

by Maintenance

‘Tis the season for holiday parties, and everyone wants to look their best. So who wants snowflakes on their shoulders?

This blog is for anyone with a scaly scalp who is looking for additional help.

As a clinical dermatologist with over a decade of experience, I have some simple recommendations you may be able to try on your own, at a low cost, before heading yet again into your doctor’s office.

Stop scratching!

Easier said than done—for sure. Consider taking an oral antihistamine at bedtime, as the ones that make you sleepy, tend to work the best. Be sure to run this by your healthcare provider, especially if you have drug allergies or take multiple medications—a phone call or secure email inquiry will do. Generally, 50 mg of Benadryl does the trick!

If you have open sores, your clinician may consider a course of oral antibiotics, as secondary infections can cause itchiness and a worsening rash. If your doctor doesn’t see overt signs of infection (such as swelling, warmth, redness, tenderness, bogginess or yellow discharge/crust), he or she may still prescribe a lower, non-antimicrobial dose of antibiotic. Newer versions of antibiotics may be used for their anti-inflammatory properties.

And remember, there is some truth to the itch-scratch-rash cycle, especially with regards to scalp psoriasis.  Although it may be tempting to scratch that itchy, scaly scalp to death with a hairbrush or fingernails, please know you may be making your psoriasis worse! Heinrich Koebner described this phenomenon, known as the Koebner phenomenon, where skin lesions will appear in the areas of minor trauma including scratching, rubbing, or sunburn. So if you’re scratching, then you may be propagating your psoriasis lesions.

Oil under occlusion can be your best friend

Thick scale on the scalp can be a real pain—literally and figuratively. If you aren’t removing it first, to “prime” your scalp skin for the real workhorse of topical corticosteroids, then you might as well be a dog chasing its tail.

Kitchen oils such as olive or coconut oils will do just as fine as medical-grade mineral and peanut oils. Baker P&S solution contains phenol to help numb and exfoliate, while prescription corticosteroid Derma-Smoothe/FS scalp oil soothes inflammation. These are obtained only by prescription, so be sure to ask your doctor.

Place your oil, or medicated oil, under a shower cap or warm wet head wrap, turban-style, for a half hour or even overnight to facilitate softening and breaking down the dead skin.

No need to do this messy oil treatment nightly, although you certainly can for periods when you have very thick scales. I’d recommend doing this only when you need it—when you have a layer of dead skin that makes your topical medications or light treatment impenetrable. For some, this may be as often as once a week to every couple of weeks. Or feel free to perform more frequently if you prefer the soothing aspects of the oil, which many do.

Descale gently with a brush or comb

Now that you’ve softened up the thick, dead skin, it should be less traumatizing and less painful to remove. Gently, yes GENTLY, use a shampoo massager brush or comb with rounded, smooth bristles to remove the scale without harming the delicate living skin below.

Banish unwanted bugs

Everyone has organisms living on and in their skin, and the delicate balance of the microbial environment changes over time and with various circumstances. The shift in flora can create itchiness and facilitate inflammation—redness, swelling, and scaliness.

This may be a great time to use a medicated shampoo, especially an antifungal or antimicrobial shampoo to further treat the skin on your scalp. Try a shampoo with the active ingredient of zinc pyrithione, selenium sulfide, ketoconazole or tea tree oil. There are many over-the-counter options, as well as those of prescription strengths.

And just because you’ve tried one active ingredient, please don’t think all medicated shampoos don’t work for you! Because each ingredient has a different antimicrobial spectrum, you may do better with a shampoo containing a different active ingredient at a different point in time. Many of my patients have one bottle of each in their bathroom and rotate use every couple of weeks.

Even when your scale seems to be in check, I recommend continuing a “maintenance” medicated shampoo a day or two a week, as the antimicrobials also have the secondary effect of decreasing inflammation. Using a medicated shampoo is much easier than using a topical steroid, and with fewer side effects!

If you prefer a scalp rinse, 1 part apple cider vinegar to 3 parts water does the trick. Be aware, it may sting initially but works well for alleviating the itch and acting as a natural antiseptic. If you have color treated hair, be sure to ask your stylist for advice. While your skin may fare well, your colored locks may do better with a medicated shampoo.

Soak, then rinse

Now, this next piece of advice is a dermatologic pearl—one that patients and fellow clinicians always appreciate and offer me thanks for explaining. I always educate my patients that medicated shampoos are best thought of as a medication that comes in the vehicle of a shampoo. They are not intended to be used as typical shampoos—to be rinsed off immediately after application. Instead, I prefer to call it a “soaking scalp lather”.

Be sure to massage the shampoo into the skin of the scalp, leaving it in place for at least 5 minutes, prior to rinsing. Prolonged contact allows for penetration of the active ingredients into the skin, instead of being rinsed away as a typical shampoo.

Consider a hair product elimination trial

A scaly scalp should not limit the use of your favorite shampoo and other hair care products…most of the time. The caveat here is contact irritation and allergy. This can occur over time and to dyes, fragrances, and even natural and organic ingredients.

If you experience itchiness after using your shampoo or hair care product, then it may be a good idea to try a hair care product “elimination.” If you can go without products, then try to do so and see if it makes any difference in your symptoms. If you feel this is absolutely not an option for you, do a trial of a hypoallergenic shampoo made specifically for patients with cosmetic allergies and free of dye, fragrance, and preservatives. Vanicream is a good brand to try. You can purchase online or ask your pharmacist to order this over-the-counter product for you. (They also happen to make hypoallergenic conditioner.)

So after using a medicated shampoo to treat your skin condition, feel free to now use your favorite shampoo and conditioner to treat your hair. You may need to do this a few times depending on how much oil you used.

The “primed” scalp is the ready scalp

Your scalp skin is now “primed” and ready to receive your topical anti-inflammatory medication(s) and/or light therapy—treatments that will address the root cause: inflammation in the skin.

Topical corticosteroids are powerful anti-inflammatory medications and are the most frequently prescribed. They come in several different forms: liquid, spray, foam, cream and ointment depending on your preference. Many of my patients prefer the spray or foam forms for the scalp. These forms tend to cost more, so many of my patients create their own sprays by putting the liquid form into their own spray bottles.

Be sure to discuss with your prescriber how often you should be applying your medication, including the maximum number of consecutive days of use. While these medications work well, “tachyphylaxis” or tolerance can develop, as can other side effects such as skin-thinning or acne-like rash. At times, systemic cortisol levels can be altered and lead to serious health effects when applied to larger body surface areas frequently.

As a result of the side effects of topical steroids, many clinicians recommend combined or rotational use of other topical medications. Other anti-inflammatory topicals include vitamin D3 analogues, calcineurin inhibitors, anthralin, and coal tar products.

Light therapy can be another steroid-sparing anti-inflammatory treatment to use in your rotation of treatments. With regard to light therapy, be sure to discuss the order of your topical therapy applications with your provider. Some topicals, such as mineral oil, Vaseline oil or glycerol may enhance UVB penetration, while other topicals, including prescriptions, may block UVB. And yet other topicals work well used in conjunction with UVB but must be applied after phototherapy to be most effective.

Not all topical scalp medications are created equal

While the beta hydroxy acid salicylic acid and alpha hydroxy acids, such as glycolic and lactic acids, are also topical medications used for scaly, scalp conditions, I think of them as chemical descalers or “keratolytics” used to enhance the breaking up of the dead, thick scales rather than addressing the root skin inflammation. I’ve found my patients prefer their use as a shampoo or scalp spray to be used for thin scalp scales or for maintenance topical therapy.

Anthralin and topical retinoids also are used for psoriasis but work in a slightly different manner to help normalize and slow down the hyperactive development of thick, scaly skin. While coal tar appears to help both shed the top layers of dead skin cells and slow down the rapid development of skin cells. Most of my patients declare Neutrogena T-gel shampoo a “must-have” in their showers.

Rotate your medicated shampoos

I know I’ve mentioned this bit of advice in a slightly different form already, but I’m going to say it again as it simply cannot be impressed upon enough. Just because you’ve tried one shampoo, please do not think medicated shampoos do not work for you. Each active ingredient works in a slightly different way and may work better at different points in time. It’s important to discuss with your healthcare provider, as well as educate yourself, on when it’s best to use each one. Many of my patients have a shampoo library in their bathrooms, rotating use of each one at a several-week interval, to address inflammation, microbial balance, and hyperactive skin development in different ways.

The rise of personalized, digital medicine offers hope

If you are reading this blog, then you already know how challenging it is to care for an itchy, scaly scalp. You know there is no cure, and that there will be good scalp days and bad scalp days. And yes, it is a lot of work! A LOT of work! Your lives revolve around caring for your skin. We need to help one another and change this.

I hope some of my advice has helped to clarify some misconceptions about how to best address itch, prime your scalp, and get the best efficacy of your topical medications and light therapy.

As you know, chronic skin disorders are complex with no two people alike, and triggers vary and change in time. With the rise of the digital age and the ability for us to share information about health and disease with greater ease via our smartphones and laptops, I hope you will share your experiences and tips with me. I always welcome a fresh perspective, as we’re all in this pursuit together.

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