Dandruff is a common skin problem and can lead to flakes and itching on the scalp. As of now, we don’t know the exact reason why it happens. However, there are several factors that can lead to dandruff. These include Malassezia overgrowth, oily scalp, skin barrier defect, hair products, and some individual factors.
Dandruff treatments are usually focused on reducing Malassezia fungus and decreasing the build-up of dead skin cells. There are several options: over-the-counter dandruff shampoos, prescription shampoos and topicals, home remedies, and lifestyle changes.
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Topical ingredients
Most people get relief from the use of over-the-counter anti-dandruff shampoos, conditioners, or leave-on products. There are several ingredients to look for in these shampoos. Each ingredient works differently.
- Keratolytic (loosening the scales)
- Antifungal (decrease Malassezia)
- Decreasing the cell turnover
If you have a lot of scales, it is better to use an ingredient that will get rid of those scales (like salicylic acid) and combine with an antifungal (like ketoconazole) which can then penetrate better to kill the fungus.
However, some people do just fine with using one ingredient if the dandruff is mild.
Also, some ingredients can do both – shed the scales or decrease turnover and kill fungus like sulfur, selenium sulfide, and coal tar (these three ingredients can also give a strong smell to the shampoo).
Different countries have different regulations when it comes to the percentage of the ingredients that can be used and whether they are over-the-counter or prescription [Product ingredients mentioned below may vary from country to country]
Let’s take a look at the ingredients:
1. Ketoconazole
This is an azole antifungal that can decrease the burden of Malassezia fungus on the scalp. It inhibits the synthesis of lanosterol, which eventually alters the fungal membrane and prevents its growth.
It can also be helpful in male pattern baldness (androgenic alopecia). It can inhibit the enzyme responsible for the conversion of testosterone to dihydrotestosterone (DHT) – which is responsible for hair loss. However, the evidence supporting this is scarce.
Nizoral shampoo is a well-known product that contains ketoconazole. You can get 1% over the counter. However, to get 2% you will need a prescription in the USA (in some countries 2% is available over the counter). A concentration of 2% is considered superior to 1% ketoconazole or 1% zinc pyrithione in treating severe dandruff.
Read more: Pyrithione Zinc vs Ketoconazole
2. Zinc pyrithione
This is one of the ingredients very commonly seen in anti-dandruff shampoos available over the counter. It is a broad-spectrum antimicrobial with antifungal and antibacterial properties.
How does it kill fungus? Several mechanisms have been proposed in various studies. Taking all these together, zinc pyrithione can impair the intake and metabolization of various nutrients by Malassezia preventing its growth.
The other property is that it has slow solubility so it is present as a particulate form in formulations (suspension). These particles can get deposited on the scalp skin and the hair follicles. The active ingredient is released over time, resulting in more sustained suppression of Malassezia.
In the US – wash-off products can be used at a concentration of 0.3 to 2 percent, and leave-on products can be used at a concentration of 0.1 to 0.25 percent.
Related: Best Zinc Pyrithione Shampoos and Pyrithione Zinc vs Selenium Sulfide
3. Sulfur
Sulfur is another great ingredient for dandruff. It has keratolytic, antifungal, and antibacterial properties. It sheds dead skin cells by reacting with the cysteine amino acid in the keratinocytes. In addition, it can be converted to pantothenic acid by normal flora and skin cells which is toxic to fungi.
It is often seen at a concentration of 2-5% in over-the-counter products. Some products may have a strong smell. It can also stain metals and light-colored hair.
4. Selenium sulfide
Selenium sulfide is an effective anti-fungal that can also decrease the cell turnover decreasing the buildup of flakes and giving symptomatic relief. It is available at a concentration of 1% over the counter (2.5% with prescription in the US).
As seen in one study, both ketoconazole 2% shampoo and selenium sulfide 2.5% shampoo are effective in the treatment of moderate to severe dandruff; however, ketoconazole 2% shampoo is better tolerated.
This is also one of the few ingredients which can disrupt the biofilm of fungi. So, if your anti-dandruff shampoo is not working give this a try.
It can discolor hair and stain some metals, so use caution if your hair is light-colored and with your jewelry.
Read more: Selenium Sulfide vs Ketoconazole
5. Coal tar
Coal tar can be useful via various properties: antipruritic, anti-inflammatory, anti-microbial and antiproliferative. Coal tar works by slowing the production of skin cells, and reducing redness, inflammation, and irritation.
It is an effective ingredient, however, rinse your hair thoroughly. It can make the scalp more sensitive to the sun so protect it using umbrellas or hats.
It can stain light-colored hair and sometimes can irritate the skin, so use caution. It might be better to start with a lower concentration. The products may have a strong smell as well.
Some products with coal tar may come with cancer warnings, due to animal studies and studies related to occupational exposure. However, studies failed to show an increased risk of cancer in individuals after using coal tar for treating psoriasis or eczema.
6. Salicylic acid
Salicylic acid is a keratolytic meaning it will shed the clumps of flakes present on the scalp. This will decrease the buildup of dead cells and reduce itching.
Its anti-inflammatory properties can further help to relieve the symptoms. In addition, when the layer of dead skin is removed, the other active ingredients can effectively penetrate the skin.
7. Climbazole
This is an antifungal and belongs to the same class as ketoconazole and both work similarly by affecting the fungi cell membranes. There is not a lot of data but it’s promising as seen in a few studies (like this study where 0.65% of climbazole was used). This is available over the counter in some countries.
8. Ciclopirox olamine
This is an antifungal with additional antibacterial and anti-inflammatory properties. In the US, CICLOPIROX shampoo 1% is available through prescription for the treatment of seborrheic dermatitis. In some countries, it is available over the counter.
In a study comparing 1.5% ciclopirox olamine and 2% ketoconazole, both led to comparable efficacy in treating scalp seborrheic dermatitis.
9. Piroctone Olamine
This is another antifungal compound found in some anti-dandruff shampoos – either alone or in combination. There are not many studies comparing it to other anti-dandruff compounds. In most studies, it is used in combination with other anti-dandruff ingredients.
In one study, a combination of 0.5% piroctone olamine and 0.45% climbazole and 1% zinc pyrithione, showed comparable efficacy in reducing dandruff.
Natural home remedies
1. Essential oils
There is some evidence that essential oils like tea tree oil, neem oil, etc. can be beneficial for dandruff. If you try these, make sure to dilute them with carrier oil like safflower oil, grape seed oil, hemp seed oil, etc.
2. MCT oil
MCT (medium chain triglycerides) oil is another one which can be helpful due to its anti-fungal properties. Biom8 is one such brand focusing on the antifungal properties of caprylic/Capric Triglyceride and tricaprylin (Caprylic Triglyceride).
I have tried BIOM8 – Skin Conditioning Oil as a massage oil for my scalp. I have not used it as a standalone product so cannot speak of its effectiveness in helping dandruff if used alone.
3. Honey
Honey has antimicrobial properties and can target Malassezia. Honey masks can be beneficial for dandruff.
Lifestyle changes
1. Gentle hair care
Be gentle with your scalp and hair.
- After washing your hair, roll a soft baby towel around your hair to absorb excess water.
- Use wide combs to detangle your hair.
- Avoid scratching as that can lead to infections, sores, and scabs on the scalp.
- Whenever possible protect your scalp from the sun with a hat or umbrella.
- If you want to oil your hair, best to do it 30 minutes to an hour before washing. This way your hair will be conditioned and there will be no oily residue.
2. Stress management
Stress can lead to flares of dandruff. So managing stress (with meditation, walking, or any way you prefer) can help in managing dandruff.
3. Healthy diet
There is no clear-cut evidence of the role of diet in causing dandruff.
However, high glycemic foods can release insulin and insulin growth factor 1 (IGF1) which in turn can increase the level of androgens. This can increase sebum output which is a factor related to dandruff.
A balanced diet is more important than completely eliminating a class of food – like trying to go dairy-free, gluten-free, or sugar-free. If you are allergic to something like gluten, it makes sense, but all together removing big groups of food can be challenging and can make your life more stressful.
So, take your dessert break here and there, but make sure to include nutrient and antioxidant-rich foods in your diet.
If you think eating any particular food has a big impact on your skin, try eliminating just that one. For more help, get in touch with a professional/dietician.
Hair care routine
If you are dealing with dandruff, it is important to treat it to prevent damage to the hair follicles and reduce itching.
- Always read the instructions given by the manufacturer to use a product. Anti-dandruff shampoos can be drying and irritating for some people, so do a little patch before you start using them.
- If you do not see any clear instructions, make sure to lather the shampoo, massage your scalp very gently, and leave that lather on your scalp for at least 2-5 mins. This will give enough time for the ingredients to work.
- Do not give up quickly, it may take 2-4 weeks to see improvement in flaking.
- You can start with a single-ingredient shampoo or a combination shampoo with two actives.
- If your dandruff shampoo stops working, try a shampoo with biofilm-disrupting properties like selenium sulfide (like Selsun) or sorbitol (like Sebclair).
- After shampooing, wrap your hair in a soft towel or simple cotton t-shirt to absorb excess water. For detangling, use wide combs to prevent hair breakage. Protect your scalp from the sun by using hats, umbrellas, or scarves.
- If you are not getting any relief or you start seeing skin redness, it is best to see a professional to get prescription shampoo or leave-on treatment products.
For straight or wavy hair
If you have straight or wavy hair, you can wash your hair as often as it can tolerate without becoming dry. But make sure to use an anti-dandruff shampoo at least twice weekly. For in-between washes, you can use your normal shampoo.
For curly hair
If you have curly hair, be careful and use an anti-dandruff shampoo just once weekly. If your skin can tolerate it and does not become extra dry or you sweat excessively, you can wash more often (maybe twice/week).
Why does curly hair need some extra care and love? The overall structure of all hair types will be the same, but the shape of the hair follicles of curly hair is different. Due to this, natural oils cannot easily flow up and down the hair shaft.
This leads to dryness of hair and eventually, they become more prone to breakage. So, curly hair can get damaged if washed too often. Washing them just once per week can be enough for some.
Maintenance
If your flakes are gone, keep using your anti-dandruff shampoo. You can reduce the frequency as per your needs.
Resistance to antifungal ingredients
We see quite commonly that an anti-dandruff shampoo was working fine and then it stopped working.
Is it due to resistance? We often see Candida species associated with biofilm formation. There are some studies where Malassezia is associated with biofilm formation as well.
What is this biofilm?
Biofilm is formed when multiple microbes (like bacteria or fungi) come together and form an extracellular matrix which helps it to attach to a surface. This biofilm can make it resistant to various antibiotics or antifungals. There isn’t much data to back it up if this can cause resistance to an anti-fungal shampoo.
But if something becomes chronic, disrupting this biofilm can help in clearing the infection. Selenium sulfide is one of the anti-dandruff ingredients that can disrupt biofilms as well.
In addition, xylitol and sorbitol can also inhibit candida biofilms. You have probably seen xylitol in many chewing gums which are meant for people with dry mouth or for reducing dental plaques.
Hopefully, we see more data on this in the future. The best way is to rotate different anti-fungal ingredients in your routine (for example ketoconazole for a few months then switch to zinc pyrithione and so on).
If you think your anti-dandruff shampoos are not working, try switching to shampoo with selenium sulfide (Selsun) or look for ingredients like sorbitol (Sebclair) in the shampoo.
Summary
Dandruff can be treated by decreasing the burden of Malassezia and getting rid of the build-up of dead skin cells.
There are multiple ingredients that can be useful, and you might have to try to see what works best for you. Some useful ingredients are – zinc pyrithione, ketoconazole, salicylic acid, selenium sulfide, and so on. Each ingredient works differently.
Combination shampoos with multiple actives might be useful if a single-ingredient shampoo is not working. In addition, try switching to selenium sulfide shampoo if the problem still persists.
Using a gentle scalp care routine is essential if you are dealing with this. If your symptoms are getting worse, it is best to see a healthcare provider.
Disclaimer: This blog post is for information purposes only and does not replace medical advice.