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Dandruff : What you need to know.

Dandruff is part of a common dermatological condition called “Seborrhoeic dermatitis” with dandruff being the most common & mildest form of the disease. It is said that 50% of the adult population worldwide are affected by it.

The title of an article published in the Indian journal of dermatology read: “Dandruff: The most commercially exploited skin diseases” which is aptly put. We’ve all seen the amount of commercially available anti-dandruff shampoos out there in the market. Their marketing strategies, using celebrities to endorse products with the labels such as “get rid of dandruff”, “100% dandruff free forever” etc. What they fail to mention is that, one will only be dandruff free, if one uses the product forever as well.

That being said there is still no clear explanation of why it occurs nor is there is cure for it yet. ( Yes, its frustrating that most dermatological conditions still don’t have any cure, but science is evolving, and so far dandruff is completely manageable)

So what causes dandruff?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4852869/

How does it present?

Seborrhoeic dermatitis can present in infancy, and is thought to be due to the maternal androgens (male hormones) that stimulate the sebaceous glands (oil producing glands) to produce more sebum. This commonly presents as “cradle cap” in infants. The condition is self limiting, which usually resolves with just regular bathing and with application of moisturisers. Medicated shampoos containing 2% ketoconazole may be required for persistent cases.

Yellowish greasy scales can be seen adherent to the scalp

Dandruff

In adults, it usually starts at puberty. In it mildest form i.e dandruff one may experience itchy oily scalp, with easily removable dry white flakes. These flakes are the upper layers of the skin (stratum corneum) that are being shed off and not dirt. It has been observed that patients with dandruff do experience an increase amount of hair loss as well.

Seborrheic dermatitis

Coming to the more serious form called seborrheic dermatitis, here,inflammation (red inflamed skin) is marked and the condition is not limited to the scalp. Areas with high amount of sebaceous glands may be involved as well such as behind the ears, around the nose and mouth, forehead, chest. Patient will present with recurrent flares of such red itchy skin with greasy yellow scales. These flares are usually precipitated by emotional stress.

Source: Bolognia: textbook of dermatology

Now lets see how it can be managed.

Firstly its important to remember that there is no one time cure for dandruff or seborrheic dermatitis.

Dandruff may occur in individuals who have never experienced it before, if the conditions mentioned as the causes find a favourable environment and it may also resolve once such conditions are removed.

Avoid hair oil application, this can favour the over growth of the yeast Malassezia (or if that’s something you’re used to doing and do not want to give that up, then strictly avoid applying to the scalp & apply the oil only to the hair)

Use shampoos specially labelled “anti-dandruff”, but remember not to blindly trust labels, and look for ingredients such as anti-fungals (active against the yeast) like 2% ketoconazole, selenium sulfide, ciclopirox olamine, and 1% zinc pyrithione (helps regulate sebum production). Salicylic acid helps remove the excess sebum and helps exfoliate the flakes better.

Use 2-3 times per week for at least a month.
Massage gently into the scalp, leave for ~ 2-3 mins and rinse it off. Continue using such shampoos once a week for maintenance even when the dandruff has cleared. This will help prevent recurrence.

Conditioners can be used as usual, which is to be applied only to the hair shaft avoiding the scalp.

Bioderma Nodé DS antidandruff shampoo contains Zinc pyrithione, & salicylic acid as active ingredients. It also contains sodium shale oil sulfonate (extract from fine grained sedimentary rocks), which is approved in Europe for its anti inflammatory properties. This shampoo helps remove the flakes from the scalp, helps those with the oily sclap and also acts on the yeast. Advantage: Effectively controls dandruff, does not dry the hair out and has a neutral smell. Disadvantage– Expensive ~ Rs 1400, some people may actually prefer some scent to their shampoo.

Neutrogena T/Sal shampoo : Also conatins salicyclic acid as active ingredient. Ideal for oily scalp. Price – ~1300

Over the counter affordable anti dandruff shampoos containing zinc pyrithione.

Loreal professional anti dandruff shampoo contains zinc pyrithione with salicyclic acid. MRP – Rs 590

Scalpe + shampoo contains both ketoconazole and zinc pyrithione. Also does not dry out the hair.

Dove anti-dandruff shampoo contains zinc pyrithione but also ingredients that helps with hydrating the hair.

When to see a dermatologist?

When the skin on your scalp, face etc is red, itchy with yellowish greasy scales which in this case the seborrheic dermatitis may require a course of topical steroids to bring the inflammation down.

When the redness extends beyond the hairline and the scales are firmly adherent to your scalp,this could be a form of psoriasis instead.

Picture source:https://www.webmd.com/skin-problems-and-treatments/psoriasis/ss/slideshow-scalp-psoriasis-tips

When you notice your child having patches of hair loss, with either pustules (boils) or scaling, in this case, examination by a dermatologist is necessary to rule out fungal infection.

Pic source:https://www.webmd.com/skin-problems-and-treatments/picture-of-ringworm-of-the-scalp-tinea-capitis

Here are some questions I’ve received on this topic.

1. Could you suggest shampoos for dandruff that does not cause hairfall?

The shampoos are not the cause of the hair loss but its rather the dandruff that causes it. And list of shampoos are given above.

2. Does dandruff cause hair fall? And how to promote thick hair growth?

Yes, individuals with dandruff do experience from more hair fall. Its been noticed that they have 100-200 hair fall per day compared to the normal 50-100 per day

Hair thickness is determined by your genetics, there is nothing that can change that. However for a person with male or female pattern hair loss, the terminal hair (the thick black hair on the scalp) is turned to vellus hair (thin, fine hair normally seen in other other parts) which gives the impression of thinning of hair. Its always best to get this examined by a dermatologists, since the treatment for this is completely different.

3. Does dandruff worsen in pregnancy?

Yes, it can. As you can see from the explanation on the causes of dandruff, increase activity of the sebaceous glands (which in turn produce more oil, and facilitates overgrowth of the yeast) is one of the main factors in causing dandruff. Sebaceous glands activity also increases during pregnancy especially during the 3rd trimester due to increase level of the hormones -progesterone and androgens. But fear not!! This is completely reversible post delivery. And the anti-dandruff shampoos are completely safe to be used during pregnancy.

4. Solution for oily scalp and dandruff that is not getting controlled?

Check out the shampoos I mentioned earlier containing salicyclic acid (available ay nykaa, amazon) . This should help control the excess sebum production in your scalp. Use a combination of shampoo, for example, one containing salicylic acid on one day and one containing anti-fungals on the other hair wash day. You could also increase the frequency of shampooing, like 3 times times a week with these medicated shampoos and 2 times a week for maintainence.

5. I also have a very oily scalp, and I get too many DIY suggestions from people and I don’t know which one to believe.

Management of oily scalp, check answer on question no 4. As for the DIY lemon juice, onion juice, daily hair washes etc, its all time consuming, messy, requires a lot of effort and all un-necessary for something that is not even scientifically proven. Just stick to the advises that is known to work, follow the instructions as mentioned above and you’ll be able to manage your condition in no time.

Featured picture source: Unsplash

The wedding glow

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I’ve been slacking with creating new content for the past few months, its been difficult to find the motivation sometimes especially when one is dealing with a million other things. But now with this pandemic going on, countries are facing global lockdowns and being a dermatologists and not someone working in the front lines of this health crisis, I now have more time to dedicate to this blog again. And I hope you’re all safe and well wherever you are.

As my first posts in months, I’ve decided to share something more on a personal note and not too much of the normal “science behind skincare” content I normally post.

I was lucky enough to be able to have a wedding reception in Goa recently in February 2020, just before this pandemic shook the world by storm.

I’ve been requested to share by professional advise on skin care for the upcoming brides out there. I was honoured to be featured by https://hitchedhaven.com/ (a website catering to future brides & grooms seeking to tie the knot in goa) on their website about my skincare advises as a dermatologists for “that wedding glow”.

Here are some pictures without makeup.

And the pictures from the wedding:

As a dermatologist skin care is my expertise. I’m a firm believer and advocate of evidence based consistent skin care regimen which means I use products backed up by science and I do not resort to DIY or home remedies for my skin or hair.

You plan for your wedding months ahead, similarly your skin needs the same amount of attention months prior to the big day.

Seek a consultation with a dermatologists to help formulate a skin care routine addressing your personal issues (be it acne, or pigmentation etc). Its important to start this early as there is no “fast track treatment” for such issues yet except for the magic of makeup, which can conceal anything. But if you’re someone like me who does not like wearing too much makeup and want to keep things as subtle and natural as possible then:

Find a dermatologist before you find a makeup artists.

If hydrated, clear, glowy skin is your goal without having to worry about the thick layer of makeup on your face for your wedding day especially if you’re planning to have a destination wedding in the humid climate of goa, here are some advises for you:

Use a broad sunscreen with both UVA and UVB protection. Search for one with spf 30 and above with a PA factor of +++, this will help prevent sunburns and tanning which makes your skin look dull. If you want help with your choice of sunscreen, check out my previous post: https://drnaphi.com/2019/07/15/all-about-sunscreens/

You may opt for sessions of chemical peels which helps with pigmentation and gives you a glowy youthful skin. Chemical peels are out patient procedures performed by certified dermatologists in their clinics. Higher strength acids such as glycolic, salicylic, or trichloroacetic acids etc are used in multiple sessions of 2-3 weeks apart, to help achieve a clearer skin.

Always use a moisturiser. And yes, you still need a moisturiser even if you have oily acne prone skin, and its especially important if you’re using an active ingredient for your acne such as retinoids, benzoyl peroxide etc. I have acne prone skin and below are some of my favourite moisturisers:

Facials, clean ups are optional, but if you want that extra layer of pampering, then don’t wait till the day before to do it. The reason being, in case you do experience some allergic reactions from any of these products, your skin will have the time to heal. Do it a week before the big day and maybe just use face mask sheets for the instant hydration the night before.

Your skincare does not end on your wedding day.

Remember to wash your face thoroughly after the celebration. I know you’re going to be tired after at the end of the night but trust me, you need to get that makeup and sweat from the entire day off your skin before you take your final rest.

Use a micellar water or cleansing oil as the first step to remove all the oil based makeup. Then clean your face with any cleanser after.

My go to micellar water, but there are so many other versions out there in the market. You can use any one of your liking.

Cleansers I swear by, and its not just for this special day, I use them on a regular basis.

Lastly, moisturise and enjoy your wedding night 🙂

Azaelic acid for your skin care

How does it work?

Azaelic acid has been shown to have a bacteriostatic (inhibits the growth of microbacteria) and bactericidal (kills the microbacteria) action against micro organisms in our skin particularly Priopionibacterium sp (bacteria responsible for acne).
Azaelic acid also displays anti keratinising effect i.e it inhibits the proliferation of keratinocytes (cells of our skin) which would otherwise build up and clog our pores thus leading to formation of comedone (white or black head)- precursors for acne. If you recall from my previous posts, retinoids (vitamin A derivative) also has this action. AA does not however reduce sebum production (oil secretion) in your skin unlike oral isotretinoin (vitamin A derivative used in the treatment of acne).
Azaelic acid demonstrated cytotoxic effect (toxic to cell) towards active melanocytes (pigment producing cells of our skin), which means it does not affect the inactive melanocytes in the normal skin, thus it particularly targets just the abnormally pigmented area. It also inhibits the action of the enzyme tyrosinase, which is required for melanin (skin pigment) synthesis. Therefore it is effective as a skin lightening agents and is used to treat pigmentation disorders.
Azaelic acid (AA) has been found to act as a scavenger of reactive oxygen species (ROS) therefore reduces inflammation and redness of the skin.
Source :https://www.ncbi.nlm.nih.gov/pubmed/1712709

Dermatological conditions in which Azaelic acid is proven to be beneficial

Acne:

Azaelic acid in the strength of 20% have been shown to be effective in the treatment of mild to moderate acne. Studies have shown that twice daily application of 20% AA cream is effective than a vehicle (cream without any active ingredient) in the management of acne. Significant results were only well appreciated after 12 weeks i.e 3 months of continuous use. A study has also shown that 20% AA is as effective as 0.05% tretinoin (retinoid) in the treatment of comedonal acne.

Another study comparing the effectiveness of 15% AA with 5% benzoyl peroxide and 1% clindamycin gel (other active ingredients for the treatment of acne) showed equal efficacy of AA at the end of 4 months.

All these studies as well as reports from dermatologists have noted that the average time of achieving improvement with AA for acne was ~73 days equivalent to over 2 months of continuous use.

Azaelic acid is a great option for acne prone skin especially if someone is not tolerating other active ingredients used for acne such as adapalene, tretinoin or benzoyl peroxide.

Rosacea:

AA is FDA approved in the US for the management of rosacea (particularly papupopustular rosacea). Rosacea is a condition which can present like acne with multiple red bumps with red inflamed cheeks. Patients with rosacea have extremely sensitive skin and the redness can be triggered by various stimuli such as hot drinks, smoking etc.

A case of rosacea- red inflamed skin with papules (red bumps) and dilated blood vessels

15-20% AA used topically twice a day was shown to be effective for reducing the number of papules and pustules and to a little extent the redness in patients with rosacea. These improvement were achieved over a 15 week course of treatment.

Pigmentation:

Azaelic acid either alone or in combination with various other active ingredients is used to fight pigmentation. A study on the effectiveness of topical 20% AA in patients with FST IV -VI i.e brown or Indian skin type to black African type, concluded that twice daily application of AA lighten the pigmentation after 24 weeks (6 months) and also improved the smoothness and texture of the skin (which is great if you’re trying to even out your skin tone and skin texture)

Combination of 20% AA and 0.05% tretinoin is also available for the treatment of melasma. The study to support this combination compared AA as monotheray vs the combination therapy. Patient showed faster improvement in the form of decrease pigmentation and decrease in the size of the pigmented area in the combination group than AA monotherapy. However at the end of the study, i.e 6 months both treatment form achieved similar overall results.

How to use azaelic acid ?

Studies on azaelic acid either use 15% or 20% AA applied to the entire face twice a day. The side effects are mild stinging sensation or itching for the initial few days which subsides with subsequent continuous use.

First cleanse your face using a gentle cleanser
Let your face dry for like 30 mins and then apply a small amount of AA to your entire face.
If you are new to active ingredients for your skin care, I suggest starting with a low strength such as 10% AA twice a day to a clean face which can then be increased to 15% or even to a maximum of 20% AA.
This can then be layer with a moisturiser on top.
Do not forget your sunscreen in the morning after the above routine.
AA can be used as spot treatment for the inflamed acne or rosacea as well in addition to the twice daily application.

What to expect with Azaelic acid?

AA is a good option to treat mild to moderate acne and rosacea and its safe during pregnancy and can be used safely in nursing mothers as well.

For those of you who are planning pregnancy, or are pregnant, AA is a great option to use especially for someone who was using a retinoid (which is contraindicated in pregnancy) and needs some other active ingredient for their skin care.

Azaelic acid will definitely test your patience. Acne and rosacea usually show improvement in 2-6 months while it can take upto 6 months to achieve significant results with AA for pigmentation disorders such as Melasma.

Azaelic acid available in the market

AA is available as 10%,15% and 20% cream and gel particularly used for the treatment of acne and rosacea.

Finacea 15% is available as a foam and is particularly useful for rosacea who cannot tolerate other ingredients present in the cream base.

AA is also available as a combination of 20% AA + 0.05% tretinoin cream and as a combination with trenexamic acid in a serum form.

Dr Naphisabet Wanniang

Skincare | Dermatology | Life as a PhD