What’s the strangest thing you’ve ever said to someone? I’ll go first. “Do you know you can get dandruff on your face?” This is my response when patients come to my office with complaints of redness, flaking, and itching on their faces. Dandruff, medically referred to as seborrheic dermatitis, is a very common skin condition. The main culprit is malassezia, a family of fungi that exclusively affects the skin and is implicated in several common skin conditions.
Studies have identified the presence of malassezia yeast on infant skin, suggesting the yeast can live in harmony with the various skin flora that naturally occur on human skin. For reasons not yet known, it is unclear when the yeast takes a turn from a harmless skin resident to a pathogen.
In infants, malassezia causes “cradle cap,” which looks like white, thick, greasy scales on the scalp. When seborrheic dermatitis is flaring, it presents as flaking, redness, and sometimes itching on the T-zone of your face.
On occasion, dandruff can even occur on the body, including the chest, underarms, and groin. This condition has been reported to be three times more common in men than women.
Once my patient’s shock has worn off, I reply by saying, “This is a type of yeast that lives on everyone’s skin but likes the taste of your oil glands and causes the rash.” The risk increases with age, and the incidence doubles over age 65. While this condition can flare sporadically, external triggers are also important to remember. These include:
- Weather (heat or cold): Hotter temperatures can cause sweating, which can contribute to flares. Colder temperatures are typically associated with more occlusive clothing, which is a known trigger.
- Immunosuppression: Conditions like diabetes, chronic antibiotic use, and HIV have increased the risk of seborrheic dermatitis.
- Tight clothing: Wearing tight clothing or non-breathable fabrics can result in skin-colored to inflamed bumps located on the trunk and upper arms known as pityrosporum folliculitis.
- Oil-based products: Malassezia is a fat-loving yeast. Additional oil applied to the skin can contribute to the fuel needed for yeast overgrowth.
- Activity of your oil glands: In my previous blog, I discussed the size and activity of your sebaceous or oil glands are determined by your genetics. The larger and more active your oil glands are, the more likely it is that you can develop dandruff or any presentation of the malassezia yeast.
- Emotional stress: Early studies showed seborrheic dermatitis can be triggered only days after an emotionally stressful event.
Malassezia is not only implicated in dandruff, but this yeast can manifest in many different ways on the skin. One presentation is skin-colored bumps located on the forehead, chest, and back referred to as pityrosporum folliculitis (or “fungal acne” for TikTok enthusiasts).
Alternatively, it can show up as splotchy light or dark scaly patches on the trunk called tinea versicolor. This typically is more noticeable in the summer. There are usually no symptoms, although the discoloration is quite bothersome to patients.
Treatments range from over-the-counter to prescription strength products. I typically incorporate both options and discuss both treatment and maintenance options.
Antifungal treatments like tea tree oil, selenium sulfide, and pyrithione zinc are affordable options and a great place to start treatment. Depending on your preference, the above options come in various formulations, including shampoos, conditioners, and leave-on treatments.
I recommend choosing a product that does not cause significant dryness or irritation. If you opt for a shampoo, it is recommended to leave it on for at least 3 minutes before thorough rinsing. Tea tree oil is one of the only oils that should not worsen dandruff. Studies show 5% tea tree oil-based shampoos are a safe and well-tolerated option for treating dandruff.
Newer anti-dandruff products have incorporated salicylic acid as a way to gently exfoliate scalp scaling. While an effective option in reducing scalp scaling, this does not address the root issue and should not be the only therapy.
Prescription-strength products like ketoconazole and selenium sulfide are scientifically proven to control dandruff. In severe cases, I will sometimes offer oral options like fluconazole as a weekly treatment. As an off-label option, I even use isotretinoin as this medication works to shrink oil glands to inactivity, which is why it works so well for severe acne.
For any treatment, I recommend treating until you see some resolution and then using your preferred products at least two to three times weekly to prevent flare-ups.
There is no cure for dandruff, but incorporating treatment into your daily routine can both treat and prevent symptom flares. If you have dandruff, I recommend trying the suggested OTC options. And if there’s no improvement, make an appointment with your board-certified dermatologist to discuss personalized options.
Source: webmd.com
