Dandruff is a common and annoying problem that affects at least one in two people at some time during their life. The build-up of unsightly white flakes in the hair tends to start in adolescence and, once established, is often persistent. Unless you take steps to prevent it, it can return as soon as treatment is stopped.

Types of flaky scalp

The skin cells on the scalp are continually replaced just like skin elsewhere on the body. Dead cells that fall off are usually washed or brushed away without any problem. If the cells are replaced at a faster than normal rate, or if the scalp is excessively dry or greasy, dead cells may clump together to form larger, visible flakes.

There are three common causes of visible flakes on the scalp or on the shoulders of your clothes.

• The mildest form is due to dry skin on the scalp, which causes a light smattering of dead skin cells.
• Dandruff, known medically as pityriasis capitis, causes more apparent excessive flakiness, usually with an oily or greasy scalp, but no underlying redness or inflammation.
• More severe dandruff, associated with inflammation, redness, itching and a build-up of dry or greasy yellow scales is known as seborrhoeic dermatitis.

Other conditions that can trigger dry, scaly dandruff-like symptoms include stress-related skin scaling (neurodermatitis), contact dermatitis (eg due to an allergy to ingredients in a shampoo), eczema, psoriasis and sunburn.

Sometimes flaky scalp is associated with thinning hair, in which case a caffeine shampoo can also help.

Dry flaky scalp

A dry scalp with light flaking is more common in the winter months due to central heating which reduces air humidity. A dry scalp can also result from lack of essential fatty acids, vitamins and minerals. A dry flaky scalp can also result from irritation due to factors such as hot or cold air, using too many hair products, or leaving them on your hair too long.

Dandruff

Dandruff is associated with the presence of skin yeasts. Everyone has small quantities of yeast on their skin, even people with healthy, non-itchy, non-scaly scalps. The most common culprit when it comes to dandruff is known as Malassezia furfur.

Once the level of scalp Malassezia starts to rise, the symptoms of dandruff – scaling, flaking, itching and greasiness – usually set in. In some people with dandruff, the yeasts are present in large numbers, while in others the presence of even small amounts of yeast is associated with intense hypersensitivity reactions due to immune reactions against Malassezia proteins.

Seborrhoeic dermatitis

Seborrheic dermatitis is associated with hypersensitivity reactions to skin yeasts. This sets up an inflammatory reaction in which typical yellow-white, greasy flakes cling to areas of skin that are red, itchy or even sore.

Dandruff due to seborrhoeic dermatitis can spread to involve the ears, eyebrows, nose and chest as well as the scalp. Seborrhoeic dermatitis is most common in males (although females are affected, too) and may also cause inflammation of the eyelids (blepharitis) and even inflammation of the end of the penis.

Which do you have – dry scalp, dandruff or seborrhoeic dermatitis?

The three forms of scalp flakiness can usually be told apart as follows, and need different treatment.

Whichever type of scalp flakes you have, wash your brushes, combs and hats regularly to avoid re-contaminating your hair or the problem is likely to recur.

Treating a dry flaky scalp

To treat light, small flakes of skin due to a dry scalp, you just need a cleansing and moisturising shampoo. I like Barefoot SOS Dry Scalp Treatment Shampoo which is soothing, hydrating and suitable for dry skin conditions including eczema and psoriasis. This will resolve the underlying dryness and flaking without irritation. Other options include Weleda’s moisturising calendula (marigold) baby shampoo, or a hypoallergenic shampoo if you think you could be allergic to shampoo ingredients.

Treating dandruff

A natural anti-dandruff shampoo will usually solve dandruff by eradicating the causative Malassezia skin yeasts. If your hair is oily, wash your hair using luke warm rather than hot water to avoid stimulating sebaceous (oil) glands on the scalp.

One of the nicest anti-dandruff shampoos I’ve tried is the Spanish best-selling range from Natur Vital which has just launched into the UK. These plant-based anti-dandruff formulas underwent clinical testing by the University of Barcelona. Results showed that using the shampoo every other day, for 6 weeks, produced visible effects after the first use and a significant improvement (70% reduction) within 3 weeks. After 6 weeks, the severity of dandruff was greatly improved (81% reduction) with no irritation, discomfort or skin reactions.

Natur Vital anti-dandruff shampoos are formulated for either normal or greasy hair and contain an active plant extract derived from the bark of the Jua or Jujube tree (Ziziphus joazeiro) plus licorice extracts and the anti-fungal agent, zinc pyrithione.

Natur Vital Anti-Dandruff Shampoo for Normal Hair also includes soothing calendula (marigold).

Natur Vital Anti-Dandruff Shampoo for Greasy Hair contains additional citrus extracts (astringent).

Natur Vital Bio Dandruff Control Shampoo contains the Jua extract plus Aloe vera leaf extract (soothing and anti-inflammatory) in a vegan-friendly formula, for those who prefer a totally natural formula without zinc pyrithione.

NaturVital Anti-Dandruff Shampoos are currently only available in the UK from Boots stores and Boots.com (which ships abroad to some countries). Slightly different anti-fungal shampoo based on hops, fennel and thyme extracts  are available from Amazon.com in the US.

Other anti-dandruff treatment options include shampoos that contain Australian Tea Tree oil, neem oil, lemon oil, cypress oil, sage oil, rosemary oil, or other natural anti-fungal ingredients such as coal tar. These tend to have a strong smell, but they certainly work.

Coal tar extracts are particularly helpful if you have scalp eczema or psoriasis as they help to suppress the over-production of skin cells.

Shampoos containing other antifungal agents (eg selenium sulphide or zinc pyrithione on its own) can control mild dandruff but many of these formulas are not that effective in my clinical experience. Their lack of efficacy is even alluded to in descriptions such as ‘no visible flakes from a distance of 2 feet with regular use’. I don’t know about you, but no visible flakes from two feet isn’t an attractive proposition. The best result is no visible flakes even when close up!

If the above approaches don’t solve your dandruff, then chances are you have seborrhoeic dermatitis, so move on to using a ketoconazole anti-fungal shampoo, as detailed below.

Treating seborrhoeic dermatitis

At one time, shampoos containing the antifungal agent, ketoconazole, were only available on prescription. Now, they are more easily accessible and in almost all cases will quickly eradicate scalp yeasts. Ketoconazole works by blocking the ability of Malassezia yeasts to make ergosterol – an important building block of fungal cell walls.

My go-to treatment for seborrhoeic dermatitis and problem dandruff is Nizoral 2% Shampoo, which is virtually odourless and has an attractive pink tint. Nizoral shampoo contains ketoconazole which  has almost magical results against Malassezia yeasts and seborrhoea. Wash your hair, gently massaging the shampoo into your scalp, and leave on for 5 minutes before rinsing. The only down-side is that in the UK, the bottles are soooo tiny – just 60ml each. This means they run out quickly.In the US, bottle sizes are larger at 125ml (4oz) and 200ml (7oz) sizes but the strength is reduced at 1% ketoconazole for over-the-counter use.

When applied topically to the scalp, ketoconazole in Nizoral shampoo is not significantly absorbed, and according to the patient information leaflet, there are no known risks associated with using Nizoral shampoo during pregnancy or breastfeeding (but do check with your own doctor first).

At first, you use Nizoral Shampoo twice a week for a month, by which time the build-up of flakes should have gone. Then use Nizoral once a week to prevent the dandruff returning. You can use a plant-based shampoo such as Natur Vital in between Nizoral treatments, as needed.

Dandruff home remedies

If you have a build-up of stubborn flakes that cling to the scalp, you can usually loosen them by gently rubbing with a tablespoon of argan oil, coconut oil, evening primrose oil or flaxseed oil before shampooing. This oil treatment helps to soothe sensitive skin and damp down inflammation. Then, brush your hair with a clean, natural-bristled brush (select a soft one if your scalp is tender) to remove the loosened crusts. If scales cling stubbornly, you can leave the oil on overnight, and wear a shower cap or turban to protect your pillow case. After a few treatments, most scales should have gone.

If your dandruff doesn’t clear up within two weeks of using Nizoral anti-fungal shampoo, or if inflammation is more widespread, consult your doctor. Seborrhoeic dermatitis in the eyebrows or elsewhere may need treatment with a combined antifungal/corticosteroid cream or other treatment.

Occasionally, dandruff is due to another skin problem such as psoriasis or ringworm affecting the scalp which needs to be properly diagnosed and treated.

Nutritional approaches for flaky scalp conditions

To reduce inflammation, increase your intake of healthy fats by eating more nuts, seeds, oily fish, avocado and olive, rapeseed, hempseed or flaxseed oils, which will help to reduce dryness and combat excessive greasiness. I also recommend taking an evening primrose oil supplement to moisturise the skin from the inside.

Lack of certain vitamins and minerals can trigger a dry scaly scalp, especially lack of vitamin A (found in animal products, and formed from carotenoid pigments in yellow-orange fruit and vegetables), vitamin B2, vitamin B3 (found in wholegrains, green leafy vegetables and beans), vitamin C (eg berries, guava, pink grapefruit), biotin (eg oily fish, wholegrains, nuts), and the minerals iodine (marine fish, seaweed), manganese (green tea and other green leaves), selenium (eg Brazil nuts) and zinc (eg seafood, meat, wholegrains). Vitamin B6 also helps to prevent dandruff and is found in cereals, egg yolk and liver.

You may find that taking a multivitamin and mineral supplement will help – trial one for a month or two and see if you notice a difference. Click here to read my post on the best multivitamin supplements.

Foods to avoid if you have dandruff

Some foods promote inflammation and scaly scalp problems. Cut back on processed foods, margarines and omega-6 rich oils such as corn oil, safflower oil and sunflower oil. It will also help to avoid excess sugar by following a low-glycaemic diet. Some people find that avoiding cows’ milk products help – replace these with almond or soy milk products for two weeks to see if this reduces your scalp flaking. Ensure you obtain calcium from other sources such as wholegrains, broccoli and dark green leaves, however.

This same dietary advice is also valid if you have dandruff or seborrhoeic dermatitis.

Image credit: deagreez/bigstock; wikimedia;