How to manage dandruff

Due to its prevalence and a cosmetic-only impact on patients, dandruff is ideally managed in a primary care setting. But what is dandruff? Dandruff (pityriasis capitis) is a common, chronic, and relapsing scalp condition characterised by diffuse white or yellowish scaling (with or without mild pruritus). It represents the mild end of the seborrhoeic dermatitis spectrum and affects up to one in two adults at some point in their lives.

Diagnosing dandruff in primary care

Diagnosis is clinical and based on:

• Fine white or greasy yellow scales on the scalp
• Mild itch (often present, but not universal)
• No or minimal erythema
• No hair loss or scarring

Additionally, GPs should examine the scalp under good lighting and ask about:

• Itch
• Flaking
• Seasonality (often worse in winter),
• Stress, and
• Response to previous treatments

Certain symptoms may suggest alternative diagnoses. These include:

• Thick plaques with well-defined borders extending beyond hairline → consider psoriasis
• Patchy hair loss or broken hairs → consider tinea capitis
  
• Marked erythema, oozing, or crusting → consider inflammatory dermatoses or infection
• Infants, immunosuppressed patients, or treatment-resistant disease → consider referral

Dandruff pathophysiology

Although most patients see dandruff as a predominantly cosmetic issue, the condition is also associated with:

• Overgrowth of Malassezia yeast on the scalp
• Increased sebaceous activity
• Individual inflammatory susceptibility

According to this, the treatment is usually antifungal and keratolytic rather than purely cosmetic.

First-line management

Medicated shampoos are the mainstay of anti-dandruff therapy. GPs should advise patients to use medicated shampoos two to three times weekly for two to four weeks, then gradually switch to maintenance. Patients should massage the shampoo into the scalp (not just hair) and leave it in place for several minutes before rinsing.

Here is a more detailed breakdown of common shampoos, according to their active ingredient:

Adjunctive scalp care includes avoiding harsh detergents and daily aggressive washing. It is also beneficial to minimise hair oils, pomades, and occlusive styling products. Finally, yet importantly, it is vital to manage contributing factors such as stress and sleep deprivation.

Second-line therapy

If significant inflammation or itch is present, GPs can consider adding a low-potency topical corticosteroid (e.g. hydrocortisone 1% scalp lotion) once daily for up to seven days, as second-line therapy.

Additionally, consider ketoconazole 2% shampoo twice weekly long-term in relapsing disease, but avoid prolonged steroid use on the scalp to prevent skin atrophy and tachyphylaxis.

Patient education

Key points to emphasise in primary care are that dandruff is chronic and relapsing, and not a hygiene failure. Regular maintenance therapy prevents recurrence, and improvement usually takes two to three weeks. Switching shampoos periodically can prevent reduced efficacy.

When to refer

Even GPs trained in general dermatology should refer immunocompromised patients and infants to dermatology, and other patients if there is:

• No response after four to six weeks of appropriate therapy
• Diagnostic uncertainty (psoriasis, tinea, scarring alopecia)
• Severe seborrhoeic dermatitis involving face, chest, or flexures

Patients with dandruff are common in primary care. However, the issue is benign and very manageable at this level. A structured approach using antifungal shampoos, short-term anti-inflammatory therapy when needed, and patient education can achieve good long-term control in most patients without referral.

– Dr Rosmy De Barros

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References

• Gupta, A. K., Landells, I., Talukder, M., Chow, E., Ahluwalia, R., Jasso Olivares, J. C., Vezina, N., Yadav, G., Raad, E., & Dayeh, N. R. (2025). Understanding the Scalp: Dandruff and Seborrheic Dermatitis. Journal of cutaneous medicine and surgery, 29(5_suppl), 20S–26S. https://doi.org/10.1177/12034754251368845

   

• Locker, K. C. S., Bacon, R. A., Caterino, T. L., Breyfogle, L., Alperet, D. J., Sarkar, P., Piliang, M., & Davis, M. G. (2025). Understanding the dandruff flare-up: A cascade of measurable and perceptible changes to scalp health. International journal of cosmetic science, 47(4), 703–717. https://doi.org/10.1111/ics.13067

   

• Jourdain, R., Moga, A., Magiatis, P., Fontanié, M., Velegraki, A., Papadimou, C., Rahoul, V., Guéniche, A., Chopra, T., & Gaitanis, G. (2023). Malassezia restricta-mediated Lipoperoxidation: A Novel Trigger in Dandruff. Acta dermato-venereologica, 103, adv00868. https://doi.org/10.2340/actadv.v103.4808

   

• Wang, L., Liu, H., Li, N., Wang, Y., Liu, Q., Zheng, Y., Yang, D., & Wu, W. (2025). Effectiveness and tolerance of medicated shampoo containing selenium sulfide and salicylic acid in patients with seborrheic dermatitis. The Journal of dermatological treatment, 36(1), 2506676. https://doi.org/10.1080/09546634.2025.2506676

   

• Vano-Galvan, S., Reygagne, P., Melo, D. F., Barbosa, V., Wu, W. Y., Moneib, H., & Piraccini, B. M. (2024). A comprehensive literature review and an international expert consensus on the management of scalp seborrheic dermatitis in adults. European journal of dermatology : EJD, 34(S1), 4–16. https://doi.org/10.1684/ejd.2024.4703