Update on management of dandruff and scalp dermatitis

Dandruff and seborrheic dermatitis are prevalent, chronic relapsing scalp disorders, often leading to significant psychological distress and impairment of quality-of-life. Dandruff is a milder form of seborrheic dermatitis characterized by mild scaling, itching and no visible inflammation, while seborrheic dermatitis is a more severe condition with red, scaly and often inflamed lesions. Seborrheic dermatitis typically involves the sebaceous areas of the scalp and also affects other seborrheic or oil-producing regions of the body. Despite the high prevalence of these conditions, research specific to their epidemiology and management in Canada is limited. A recent review by a group of Canadian experts examines the etiology, epidemiology and management of dandruff and seborrheic dermatitis from a Canadian perspective. It highlights the role of Malassezia species in the pathogenesis of both conditions and explores the influence of genetic, environmental and microbial factors. Recently, 11 gene mutations or protein deficiencies were recognized as contributors to the development of seborrheic dermatitis.The review highlights the diverse clinical presentations of dandruff and seborrheic dermatitis across different ethnicities. For example, in the Canadian population, patients with darker skin tones may suffer from a more severe variant of seborrheic dermatitis known as petaloid seborrheic dermatitis. Dandruff and seborrheic dermatitis are also more common among HIV-infected and immunodeficient patients, including patients with hepatitis C, chronic alcoholic pancreatitis and various forms of cancer.Management The goal of treating dandruff and seborrheic dermatitis is to reduce the proliferation of Malassezia spp., to prevent or stop symptoms. Over-the-counter (OTC) shampoos, such as those containing coal tar, selenium sulfide, ketoconazole, tea tree oil, salicylic acid and zinc pyrithione, have multiple effects on the skin including antifungal and anti-inflammatory activity, and also regulate the skin barrier. Dandruff is usually effectively controlled with these OTC shampoos, but different products may have to be tried to find the one that works best in reducing flaking.Mild seborrheic dermatitis symptoms may be controlled with OTC shampoos containing selenium sulfide, zinc pyrithione, coal tar or tea tree oil. A medicated shampoo with selenium sulfide and salicylic acid was recently shown to significantly improve dandruff, scalp redness, itching and greasiness in seborrheic dermatitis. For long-term control, antifungal shampoos containing ketoconazole may be used daily or several times a week for a few weeks to obtain remission, followed by once-weekly use to prevent relapse. Topical corticosteroids may be used for seborrheic dermatitis with scalp inflammation, but the authors warn of possible side effects associated with long-term use. Generally, corticosteroids should be reserved for short-term use during acute flares and applied only to areas of active inflammation.Moderate to severe seborrheic dermatitis Suggested treatments include clobetasol 0.05% shampoo twice weekly, alternating with ketoconazole shampoo, to reduce acute symptoms more quickly and maintain control longer after discontinuing use. If symptomspersist despite these therapies, a systemic anti-inflammatory medication may need to be added; referral to a dermatologist is advised.Treatments such as 2% miconazole and 2% ketoconazole may reduce Malassezia proliferation and scalp inflammatory response. Ciclopirox olamine can be added for antibacterial action. Roflumilast 0.3% foam is a recently Health Canada-approved nonsteroidal topical option for managing seborrheic dermatitis. It might be particularly useful for patients seeking alternatives to corticosteroids and antifungals.Resistant conditions Oral antifungals drugs (e.g., itraconazole, fluconazole) are suggested. Oral ketoconazole is not recommended first-line, due to its potential hepatotoxic adverse effects. Resistant, moderate or severe cases may respond to a low dose of the retinoid isotretinoin for six months. Severe flaking seborrheic dermatitis may require a prescription for a shampoo or topical cream, and possibly oral retinoids or hormone therapy to reduce sebum levels.Treatment of scalp seborrheic dermatitis centres on medicated shampoos containing antifungal agents (e.g., ketoconazole or selenium sulfide), zinc pyrithione, coal tar or salicylic acid, which are effective due to their ability to remove scales and delivermedication through hair. Seborrheic dermatitis on nonscalp areas is usually managed with topical antifungal creams, low-potency corticosteroids, and topical calcineurin inhibitors (e.g., tacrolimus or pimecrolimus) for sensitive areas such as the face and skin folds to avoid steroid-induced skin thinning. Topical roflumilast foam can be used as a nonsteroidal option for both scalp and nonscalp seborrheic dermatitis, as an alternative to traditional therapies.The authors emphasize the lack of a Canadian consensus on the management of dandruff and seborrheic dermatitis. Questions that need to be answered include what treatment to use first line and second line, how often to use specific products, what treatment regimen to follow, how side effects fit into the management equation, which patients should avoid certain products, how to manage relapses, and the compatibility of combining various therapies. The authors urge further research to address these questions, leading to the development of formalized guidelines to better inform healthcare providers and improve patient care. With Canada’s diverse population and the increasing burden of dandruff and seborrheic dermatitis, a more tailored approach to treatment is needed to address the challenges posed by these chronic conditions.Reference1. Gupta AK, Landells I, Talukder M, et al. Understanding the scalp: dandruff andseborrheic dermatitis. J Cutan Med Surg 2025;Oct 24:12034754251368845. https://journals.sagepub.com/doi/10.1177/12034754251368845 (accessed November 5, 2025).

Update on management of dandruff and scalp dermatitis

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