That dry, itchy scalp might not be dry at all

Dr. Crutchfield, I seem to be having a problem with dandruff and a dry, itchy scalp, especially this winter. Can you help me?

Your concern over a dry, itchy scalp is a very common one. In fact, I see several patients every day with the same complaint.

I tell patients that when it comes to treating dry, itchy scalps, I have good news and I have bad news. The bad news is that there is no cure for the condition, but the good news is that it can be managed and controlled to the point where it seems like it does not exist.

The surprising fact is that the condition that everyone seems to think of as dry, itchy scalp is not dry at all. It is a unique type of eczema (also known as dermatitis) that makes the scalp seem like it is dry because it produces lots of flakes.

 The flakes are not a result of the skin being dry; rather, the skin grows too fast as a response to inflammation in the scalp. Sheets of skin pile up because they can’t be shed quickly enough. The inflammation is driven in part by the oil production or sebum in the scalp.

This massive amount of skin flakes tricks us into thinking it is dry skin when it really is not. It is a very common skin condition called “seborrheic dermatitis.” The condition is so common that it probably affects 25 percent of all people to some degree. It can occur on the scalp, face (especially sides of the nose), eyebrows, ears, chest, belly button, groin, armpits, and even the backside’s “gluteal cleft.” 

For now, I will only talk about seborrheic dermatitis when it occurs on the scalp. The familiar, non-medical name of seborrheic dermatitis when it happens on the scalp is dandruff. It is a common skin disease that causes the skin to be red, itchy and flakey.

Seborrheic dermatitis can wax and wane and appear and disappear at any time. Sometimes the condition will resolve without treatment, but more often than not it may require medical treatment.

Seborrheic dermatitis can occur in all people. In babies, it is commonly called “cradle cap.” It can also occur in a baby’s diaper area. It tends to occur most often in infancy and adulthood and in men more than women. It is more common among family members, in people with oily skin, and for some odd reason in people with Parkinson’s disease and HIV.

The condition is harmless and not contagious, although it certainly is a nuisance. The constant itching and abundant skin flakes can be extremely problematic and embarrassing. 

Interestingly, the exact cause of seborrheic dermatitis is still not completely understood. Perhaps the excess oil in our skin serves as a food source for yeast that commonly live on everyone’s skin. The yeast grow, and for some unknown reason some people have a brisk reaction to the larger population of yeast on the surface of the skin. This response comes in the form of inflammation (redness, flaking and itching).

The yeast component is only a part of the problem. The other part is purely genetic, and the common areas are prone to inflammation with or without yeast. The diagnosis can be made easily by an examination by a doctor, especially a dermatologist.

As mentioned earlier, there is no cure for seborrheic dermatitis. The goal is management and control of the condition until it is unnoticeable and no longer a nuisance.

For scalp seborrheic dermatitis, I have a two-part treatment plan. First, let me say that I am not a big fan of using a hair shampoo to treat a skin condition. I recommend a medicated oil applied once per week to reduce and maintain scalp inflammation. This part is the maintenance program.

Washing one’s hair weekly is also very important. I recognize that weekly hair washing may be a challenge for some, but it is essential to clean the scalp skin and wash away the dead skin and flakes that are continually building up.

Secondly, I have a very potent topical treatment to use for five days if the condition should flare up and break through the maintenance program. Three two-treatment steps work exceptionally well.

If you or a loved one has dry, itchy scalp, talk to your doctor to see if it really is the medical condition called seborrheic dermatitis. If it is, rest assured there are excellent treatment programs to make the embarrassing and troubling situation much better to the point of seeming not to be there at all.