Seborrheic Dermatitis on the Scalp The Complete Guide

This article attempts to provide a complete guide to scalp seborrheic dermatitis. Discussion includes a general introduction to the condition, specific clinical features you should know, and an extensive examination of possible treatment approaches.

For the most part, the guide is created for the common public. However, it does cover quite a bit of ground and some clinical terminology may be used. If you run into any confusion or difficulties understanding any of the concepts introduced, please let me know in the comments section at the bottom of the article.

Basics of Seborrheic Dermatitis

Before we get into the discussion of possible treatments and management approaches for seborrheic dermatitis of the scalp, let’s review the basics of the condition. Reviewing the basics can provide the foundation needed to make more informed decisions when approaching treatment.

If you’re already familiar with the condition, feel free to skip this section and head straight to the treatments section.

General statistics

Seborrheic dermatitis is a skin condition that affects an estimated 3-5% of the general population. In certain medical conditions (such as HIV/AIDS), this percentage increases and can be as high as 40-50%.

Areas affected

The most common area affected by seborrheic dermatitis is the scalp, where it is more commonly known as dandruff. However, in some cases, scalp seborrheic dermatitis may in-fact be more accurate (more on this difference later).

If your issues are restricted to the scalp, you can consider yourself on the more fortunate end of the seborrheic dermatitis spectrum. Seborrheic dermatitis can move beyond the scalp, where it is usually considered to be more aggressive and persistent.

Areas beyond the scalp include:

  • Nasolobial folds
  • Hairline
  • Ears
  • Eyebrows
  • Eyelids
  • Chin
  • Forehaed

In more rare cases, the symptoms can even be found below the neckline. With areas including the chest, upper back, and groin.

The unique feature common to all of these affected areas is that they are rich in sebaceous glands (skin glands that secrete sebum). And it is the presence of sebum, that makes the skin susceptible to seborrheic dermatitis symptoms (more on this later).

What makes the scalp unique is that it not only has a high density of sebaceous glands but is also covered with hair (usually). Whether or not this (presence of hair) has a significant impact on the likelihood of seborrheic dermatitis remains undetermined; it does limit treatment choices.

Primary symptoms

The hallmark symptoms of seborrheic dermatitis include:

  • Skin flakes (can significantly vary in size)
  • Dryness
  • Inflammation and redness
  • Irritation and skin sensitivity
  • Itch
  • Excessive sebum production (not always)

And if you’ve had the misfortunate of having to deal with seborrheic dermatitis, you know that the flares can come in waves. Sometimes the symptoms die down, while other times, the skin erupts and can be extremely hard to control.

Importance of accurate diagnosis

If you think your facing seborrheic dermatitis but are not confident you have the right diagnosis, this may be an area that deserves more focus.

An accurate diagnosis is one of the most important factors to successful management of the condition. Without an accurate diagnosis, you may be literally throwing away your money trying to treat a condition that has a completely different underlying mechanism and cause.

The Cause of Seborrheic Dermatitis

Seborrheic dermatitis is a skin condition that is not fully understood and many unanswered questions remain. Even after decades of research, the underlying cause of seborrheic dermatitis remains elusive.

It’s possible that with the rate of progress we’re seeing in genetic sequencing, a more clear picture may emerge. But for now, the current working theory is the closest thing we have to an explanation.

This working theory revolves around an interaction between three key elements:

  • Malassezia yeasts
  • Sebaceous gland secretions
  • Individual susceptibility

Taken together, these three factors are at the frontline of most medical literature on the subject.

The overall skin microflora needs more attention
More recent research also suggests that the overall microbial community (collectively known as the skin microflora) may play a more important role, then the Malassezia yeasts on their own (more on this later).

Malassezia yeasts – the primary suspect

Over the years, the Malassezia yeasts have gotten the most attention.

Malassezia are considered to be commensal skin inhabitants and part of the normal skin flora. This means they are present on the skin of most humans and usually cause no negative effects for the host (human whose skin they reside on).

Under the right circumstances, these yeasts can transition to a pathogenic form and cause conditions such as pytrisias verisocolor or malassezia folliculitis [1].

In the case of seborrheic dermatitis, things aren’t that clear. Even though the yeast has not been seen to transition to their pathogenic (hyphae) form in seborrheic dermatitis [2], they are still implied in the pathogenesis of the condition.

Much of the reasoning behind this has come from the simple fact that anti-fungal agents cause rapid clearing of symptoms. This, in turn, has been related to the reduction of Malassezia activity at the skin surface. Due to this casual relationship, decades of research have reasoned the yeasts play a critical role in the skin condition [3].

Accordingly, the primary understanding that exists today is that abnormal proliferation of Malassezia yeasts is at heart of seborrheic dermatitis. If Malassezia activity is reduced, symptoms are usually quick to reside.

Possible role of individual Malassezia species
Comparison of the microflora between individuals affected by seborrheic dermatitis and those unaffected showed differences in the relative concentrations of specific Malassezia yeast species [4].

Oleic free fatty acids and irritation

Malassezia yeast depend on lipids (fats/oils) for growth and reproduction. Lucky for them, our sebum is naturally rich in lipids. Making our skin the perfect environment and our sebum an excellent nutrient source for these yeasts.

During the degradation of our sebum, Malassezia leave behind various by-products (such as enzymes, free fatty acids, and phospholipases). One of these by-products is oleic acid in its free fatty acid form.

Even in the absence of Malassezia yeasts (by reducing their numbers with pre-treatment with anti-fungal agents), researchers noticed that direct application of oleic acid (in free fatty acid form) – in prone individuals – can act as an irritant, cause barrier breakdown, and trigger the exact symptoms seen in seborrheic dermatitis and dandruff [5, 6, 7].

Thus, it’s possible the primary symptoms of seborrheic dermatitis symptoms are caused by oleic free fatty acids left behind by malassezia yeasts, rather than the yeasts themselves. In this scenario, the malassezia yeasts simply play a contributory role, by producing oleic acid at the skin surface.

Importance of a healthy skin barrier

Your skin is one your biggest organs and is at the forefront of your bodies interaction with the outside world. Accordingly, the top layer of skin has various strategies it implements to keep foreign invaders and antigens at bay. Taken together this important first line of defense is known as the skin barrier.

Unfortunately for those of us affected by seborrheic dermatitis, this barrier has been shown to be compromised and external antigens are more easily allowed to penetrate deeper layers of the skin [8]. This not only leads to increased irritation and inflammation, but to excessive moisture loss and skin dryness as well.

While oleic acid can directly cause barrier disruption, individual differences in skin barrier function are likely one of the key factors that actually determine whether your affected by seborrheic dermatitis or not. In theory, if the barrier is competent enough, topical irritants should be neutralized early enough, preventing further activation of the skin’s immune system.

Recent insights and future direction

The microbial aspect

Though most focus around seborrheic dermatitis is usually on the fungal aspect (malassezia), more recent investigation in this area has revealed the bacterial flora of the skin may actually play a more significant role [9, 10].

Overall skin micrflora is likely to play a more important role in seborrheic dermatitis than malassezia alone

Some relevant conclusion of such studies include:

  • Bacteria species residing on the skin have a stronger relationship with the severity of dandruff than fungi [11]
  • Both bacterial and fungal communities are associated with dandruff and seborrheic dermatitis, but the physical symptoms of these conditions have a more clear relationship to the bacterial flora of the skin [12]
  • A microbial shift of the entire skin microflora is more closely related to seborrheic dermatitis than the malassezia yeast populations [13]

Accordingly, perhaps future research in this area may reveal new treatment approaches and long-term management strategies.

Lipids and skin pH

Digestion, microbiome, and clues for psoriasis

Unique Features of Seborrheic Dermatitis on the Scalp

There are certain features which make scalp seborrheic dermatitis unique. These features not only influence the development of the condition but also impact the choices of treatments available.

Recognition of these unique features can provide valuable insight into the overall condition, while also improving your chances of successful treatment.

Dandruff or seborrheic dermatitis?

When it comes to the scalp, seborrheic dermatitis and dandruff are often used interchangeably. However, are they really the same condition or two different skin conditions?

Most medical literature does in-fact use the two terms to describe the exact same skin condition. The main difference being that dandruff is strictly limited to the scalp region, while seborrheic dermatitis affects regions beyond the scalp [14].

Disagreement does exist and some researchers provide further differentiation between the two:

  • Dandruff symptoms are limited in severity
  • Seborrheic dermatitis is a more aggressive form of dandruff

Though not universally accepted, these differences may actually provide a more accurate representation.

Splitting the two conditions into two separate ones may allow us to get a better understanding of how dandruff transitions to the more severe seborrheic dermatitis and migrates beyond the scalp. Accordingly, it’s possible that dandruff acts as the first stage of seborrheic dermatitis progression (acting as an initial warning signal).

Clinical differences

Some authors go even further and define more specific differences between dandruff and seborrheic dermatitis [15].

Visual representation of key differences between dandruff and seborrheic dermatitis

Dandruff is:

  • A skin condition characterized by scales, subclinical (extremely difficult to detect) inflammation, and restricted to the scalp. More specifically “scattered presence of lymphoid cells and squirting capillaries in the papillary dermis, hints of spongiosis and focal parakeratosis”.

Seborrheic dermatitis is:

  • A skin condition characterized by scales, significant inflammation, and often extending to areas beyond the scalp. More specifically “spongiotic dermatitis in which mounds of parakeratosis and scale crusts form at lips of infundibular ostia”.

Though the latter more “specific” description may be a little difficult to understand, it is provided here for completeness. The primary takeaway for most readers is that scalp seborrheic dermatitis can be viewed as a more aggressive form of dandruff which features inflammation as a primary symptom.

Impact of hair on seborrheic dermatitis progression

Theoretically, the hair follicle has been proposed to act as a potential reservoir for drug delivery (improving the effectiveness of active agents) [16]. This would imply that seborrheic dermatitis treatments should work better in hair-bearing areas (as opposed to hairless areas) as the active agents have more time to do their job.

However, anyone affected by seborrheic dermatitis knows first-hand that the presence of hair makes the condition far more difficult to manage. In-line with this phenomenon, a review paper from 1993 suggests that shaving of the affected area can lead to significant improvement of symptoms or even remission of symptoms altogether [17].

Unfortunately, shaving is not an option for most readers and the presence of hair is not a factor which can be directly controlled/removed. The most we can do is acknowledge the challenges the presence of hair brings and plan treatment accordingly.

Hair products and conditioners

Some earlier researchers have also speculated that scalp seborrheic dermatitis issues may emerge without any microbial/fungal involvement; simply as a side-effect of chronic irritation of the scalp to certain unfavorable hair care products or substances in the environment/water [18].

Perhaps making changes to the products you use on a daily basis may be enough to trigger and sustain remission for some individuals.

If you’re going down this route, comparing the ingredients of products side-by-side to ensure enough differences exist will be worthwhile. However, keep in mind that many shampoos and products on the market today are very similar in nature and often use the same primary ingredients. Since the ingredients are listed in descending order, the most focus should fall on the first 3-5 items.

Heat

Some researchers have theorized that heat may play an important role in seborrheic dermatitis. Thermal imagery of the facial region reveals, that the areas most commonly affected by seborrheic dermatitis also have the highest skin temperature:

Though it is only a working theory, a possible explanation of how this occurs is as follows:

  • Increased local skin temperature -> increased malassezia activity -> increased rate of oleic free fatty acid formation

Alternatively, it’s more likely that the increased density of sebaceous glands leads to increased blood flow and results in increased skin temperature. In this case, the density of sebaceous glands plays a more critical role, while the increased temperature is merely a secondary factor.

Impact of seborrheic dermatitis progression on hair loss

Hair loss is technically not a symptom of neither scalp seborrheic dermatitis nor dandruff. However, if either condition is allowed to progress and becomes aggressive, hair loss issues often emerge.

This is understood to be the result of several factors:

  • Physical damage (think itching)
  • Blockage of hair follicles (flakes block the pores)
  • Inflammation

Taken together, the impact compounds and the hairs become weaker, thinner, and more prone to breakage [19]; resulting in significant hair loss.

A two-day survey showed the rate of hair loss for dandruff affected individuals to be around 100-300 lost hairs, while in unaffected individuals it was only 50-100 [pubb id=”18489295″]. If we assume the lower values are a good representation of healthy hair growth – the 50-100 shed hairs are replaced with the new hairs – it would mean that those affected by seborrheic dermatitis are loosing 2-6 times more hairs then they should be.

Fortunately, many of the seborrheic dermatitis treatments have been shown to reduce the rate of hair loss and help bring back a more normal rate of hair growth. Thus, by taking care of seborrheic dermatitis, you’re likely to also take care of any accompanying hair loss issues.

This topic has been previously discussed in more detail in the Reversing Seborrheic Dermatitis and Hair Loss article.

Two Ways to Approach Treatment

Since seborrheic dermatitis is a multi-faceted skin condition, treatment should aim to address two items:

  • Reduction of malassezia and oleic acid
  • Improvement/restoration of barrier function

While choosing to focus on only a single of these can still lead to symptom relief, a combined approach may allow for long-term results.

Two primary treatment approaches to scalp seborrheic dermatitis - malassezia control and barrier restoration

Irritant elimination with antifungals

Based on the working theory that symptoms are caused by by-products of malassezia activity, the primary treatment approach to scalp seborrheic dermatitis is the usage of anti-fungal agents. These agents have been shown to reduce malassezia activity and often lead to rapid symptom relief for most individuals.

With this approach, the method of action is as follows:

Antifungal -> reduced malassezia -> reduced oleic -> symptom relief

Nonetheless, there is still some contradictory evidence that suggests that many of the commonly used antifungal agents may have a different mode of action. In the lab, these agents effectively suppress malassezia [20, 21, 22], but in real-world usage, the impact on skin surface malasssazia numbers is minimal [23]. It’s possible that some of the other properties (such as a shift in fungal/host gene expression or impact on the inflammatory process) of anti-fungal agents may be responsible for the symptom relief seen.

Skin barrier restoration

As you may remember from the earlier discussion, a major component of scalp seborrheic dermatitis is abnormal barrier function. Though there more systemic ways to improve barrier function (diet, environmental factor control, stress reduction, etc), specially designed topical products aimed to improve barrier function and/or prevent barrier disruption may be sufficient.

Whatever direction you take, improving barrier stability could minimize the irritant potential of both malassezia and their by-products (oleic acid), leading to gradual symptom relief.

With this approach, the mode of action is as follows:

Barrier repair -> reduced sensitivity -> lack of symptoms

In theory, this approach would allow more long-term relief as the strategy is focused on enhancing the skin’s defense capabilities, rather than eliminating malassezia which are naturally present on the skin. Though this treatment strategy is still in infancy and lacks the decades of research behind antifungal agents, it may deserve more attention in the future.

Review of Popular Treatments

Now that you have a general understanding of the two primary aspects of treatment, let’s review some specific treatments that exist.

There is no single best treatment for everyone
As everyone’s skin is a little different, there is no single treatment that works equally well for everyone. Though it can be exhausting, trying different treatments should eventually uncover the most suitable approach for your skin.

Anti-fungal shampoos grouped by primary ingredient

Since anti-fungal agents are some of the most documented and reviewed treatments for seborrheic dermatitis, anti-fungal (commonly called anti-dandruff) shampoos are probably the best approach to start with for scalp issues.

Different anti-fungal agents have different modes of action (the specific way they inhibit fungi/yeasts) and vary in effectiveness against certain malassezia species. If you’re not having any progress with a specific anti-fungal agent, trying an alternate agent can lead to a completely different outcome.

Additionally, individuals can have very specific sensitivities to individual ingredients found in skin/hair care products. Trying formulas using the same anti-fungal agent, but significantly different overall compositions may be worthwhile.

Formulas containing a certain anti-fungal agent are strikingly similar
Formulas with the same anti-fungal agent often have very similar overall product formulas. Take the time to examine the ingredients side-by-side.

Zinc pyrithione

Zinc pyrithione is the primary active agent in the worlds most popular anti-dandruff shampoo, Head and Shoulders.

Being the most common active anti-dandruff agent used around the globe, zinc pyrithione has a well-established safety profile and a limited number of reported side-effects [24].

The primary mode of action has been attributed to zinc pyrithiones proven ability to suppress a wide variety of malassezia species. Alternatively, some have proposed that the beneficial effects of zinc pyrithione on seborrheic dermatitis may be the result of it’s toxicity to epidermal cells (essentially nullifying the immune response) [25].

A study examining the effect of a 1% zinc pyrithione shampoo on scalp seborrheic dermatitis over a period of 4 weeks produced complete clearance in 28.8%, a marked improvement in 53.1%, and a moderate improvement in 11.9% of participants [26]. 5% of participants did not experience any relief and 1.3% reported worsening of their condition.

Zinc pyrithione products are plentiful. Shampoos and conditioners from common brands are easily found in most supermarkets, while specialty creams, ointments, and even soaps can be found online.

Thanks to this combination of a high treatment success rate, abundant availability, and inexpensive price, zinc pyrithione shampoos and conditioners have become an obvious choice for many individuals affected by scalp seborrheic dermatitis.

Some common zinc pyrithione products suitable for salp application include:

  • Head and Shoulders – Classic Clean (and most other Head and Shoulders varieties)
  • Neutrogena T/Gel (1% zinc pyrithione variant)
  • Suave Men 2-in-1 Anti Dandruff Shampoo & Conditioner
  • Dove Men+Care Anti Dandruff 2 in 1 Shampoo and Conditioner
  • Dove Dermacare Anti Dandruff Scalp Shampoo
  • Equate Everday Clean Dandruff Shampoo
  • Mountain Falls 2-in-1 Dandruff Shampoo (Amazon brand)
Various common name brand zinc pyrithione based anti-dandruff shampoos

Plus alternative options that may be worth considering include:

  • Vanicream Free & Clear Medicated Anti-Dandruff Shampoo
  • DHS Zinc Shampoo
  • Mizani Scalp Care Shampoo & Conditioner

Author's Experience
From my own experience, a simple zinc pyrithione shampoo can indeed produce quick results for scalp seborrheic dermatitis. However, with ongoing usage, my scalp remained feeling sensitive and my hair become significantly thinner. Then once my facial seborrheic dermatitis appeared, I was forced to look for alternative treatments approaches.

Further Reading
More information on zinc pyrithione and it’s usage for seborrheic dermatitis can be found in the Zinc Pyrithione section.

Ketoconazole

Based on the abundance of literature, ketoconazole is likely the second most popular antifungal agent for the treatment of scalp seborrheic dermatitis.

It belongs to the azole family of antifungal agents and is widely prescribed around the globe for the treatment of both seborrheic dermatitis and dandruff.

Compared to zinc pyrithione, the effectiveness of ketoconazole appears to be substantially better [27].

In the same study that was described in the zinc pyrithione section (this was actually a comparison study between a 2% ketoconazole shampoo and a 1% zinc pyrithione shampoo), ketoconazole treatment resulted in complete clearance in 39.6% of participants, while 46.2% reported marked improvement and 10.7% moderate improvement.

Similar to zinc pyrithione, the primary mode of action of ketoconazole is believed to be related to its ability to suppress malassezia in the lab. But once again, controversy exists and some researchers have proposed the effectiveness seen in seborrheic dermatitis may relate to ketoconazole’s ability to regulate either fungal and/or host gene expression or perhaps its impact on the inflammation cascade.

The most popular ketoconazole product for scalp treatment (possibly the only one) is a shampoo sold under the Nizoral brand:

  • Nizoral Anti-Dandruff Shampoo
Nizoral anti-dandruff shampoo is the primary ketoconazole option for scalp seborrheic dermatitis

Availability in other forms (creams, conditioners) does exist, but much less common and usually requires a prescription.

Author's Experience
My experience with Nizoral was limited. After only the first wash my hair felt that it had been stripped of all moisture, scalp felt tight, and overall it just didn’t seem like something I wanted to continue to use.

Further Reading
If you would like more information on ketoconazole and its usage for seborrheic dermatitis, please refer to the Ketoconazole section.

Selenium sulfide

Selenium sulfide is an anti-fungal agent that shares many features with sulfur and managed to secure its place as a popular seborrheic dermatitis treatment even amidst concerns of selenium toxicity.

Though it’s anti-fungal potential is inferior to ketoconazole in the lab [28], real-world usage shows similar effectiveness for symptom relief [29]. The biggest negative is the significantly higher chance of adverse effects [30].

The most popular shampoo to feature selenium sulfide is Selsun Blue (sold under the label Selsun in Europe):

  • Selsun Blue Medicated Dandruff Shampoo 1% Selenium Sulfide

However, both Head and Shoulders and Amazon (under their Mountain Falls label) have released alternatives:

  • Head and Shoulders Clinical Strength Anti-Dandruff
  • Mountain Falls Advance Solution Dandruff Shampoo – Selenium Sulfide (Amazon brand)
Three common selenium sulfide shampoos for scalp treatment - selsun blue in th middle

If required, it can also be found in a lotion/gel form at a higher concentration (2.5% selenium sulfide), but this might further increase the chance for adverse effects.

Author's Experience
My own experience with selenium sulfide is non-existent. It only came on my radar after I had decided to move away from the antifungal approach and focus on barrier recovery.

Further Reading
If you’re considering selenium sulfide, you may want to review the corresponding Selenium Sulfide section, for a more in-depth review.

Coal tar

Tars (including coal tar, pine tar, and sulfonated shale oil) have been found to be useful in an assortment of skin conditions [31]. From these tars, coal tar has gained the most popularity in the last several decades.

Coal tar is a by-product of coal and is considered a complex mixture of various hydrocarbons, containing as much as 10,000 individual compounds [32].

As with all other antifungals, it’s primary mode of action is most commonly linked to it’s documented ability to suppress malassezia yeasts [33].

Secondary beneficial properties include it’s ability to soften the top layer of the skin (keratolytic properties) [34] and anti-inflamattory action [35].

Whatever the mode of action, coal tar has been shown to produce significant relief of seborrheic dermatitis symptoms and can be considered a worthy alternative to more commonly used antifungals [36].

Due to its long history of use, coal tar has developed a well-documented safety profile, with some studies evaluating it affects over several decades [37].

The most popular coal tar containing shampoo appears to be the T/Gel produced by Neutrogena:

  • Neutrogena T/Gel Therapeutic Shampoo Original Formula – 4.0% Solubilized Coal Tar Extract (0.5% Coal Tar)

Other alternatives do exist, but availability remains limited (online or specialty stores). Alternative coal tar options include:

  • MG217 Psoriasis Medicated Conditioning Shampoo – 3% Coal Tar
  • ArtNaturals Dandruff Shampoo – 3% Coal Tar
  • Mountain Falls Therapeutic Dandruff Shampoo – 2.5% Coal Tar (Amazon brand)
  • Walgreens T+Plus Tar Gel Dandruff Shampoo – 4.0% Solubilized Coal Tar Extract (1% Coal Tar)
Five of the most common coal tar base anti-dandruff shampoos

Overall, it seems that the strong odor and color of coal tar have prevented more widespread adoption.

Author's Experience
My experience with coal tar was overall positive and the Neutrogena T/Gel shampoo provided sufficient relief for both my scalp and facial seborrheic dermatitis issues. Unfortunately, with time, I noticed my facial skin became increasingly sensitive to environmental factors and lacked a vibrant skin tone (if that makes sense).

Tea tree oil

Tea tree oil is an essential oil extracted (via steam distillation) from the Australian narrow-leaved paperbark tree. It has been documented to be effective against various types of fungi, bacteria, and mite species [38].

In the lab, tea tree oil has been shown to suppress various malassezia species [39, 40] and at sufficient concentration (>=5%) may be a suitable alternative for more commonly prescribed azole antifungal agents.

Though the evidence for its usage for scalp seborrheic dermatitis and dandruff is not as extensive as the previously discussed antifungal agents (research funding for natural treatments is often scarce), a study of 126 participants demonstrated a shampoo containing 5% tea tree oil can produce similar symptom relief as seen with ketoconazole and terbinafine [41].

Thanks to its broad range of action and natural origin, it has been growing in popularity. Becoming an important active ingredient in a variety of both skin and hair care preparations.

Probably the most well-known brand of tea tree oil shampoo in North America is produced under the Paul Mitchells label and it can found in most hair studios and salons:

  • Paul Mitchells Tea Tree Special Shampoo

Other brands are also widely available and can be found in most supermarkets:

  • Avalon Organics Scalp Treatment Tea Tree Shampoo
  • Thursday Plantation Tea Tree Shampoo
  • OGX Hydrating TeaTree Mint Shampoo
  • JASON Normalizing Tea Tree Treatment Shampoo
  • Trader Joe’s Tea Tree Tingle Shampoo
  • Maple Holistics Pure Tea Tree Oil Shampoo

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But other specialty/local brands exist as well.

You can also obtain tea tree oil in its pure form and dilute the oil to your own preference and tolerability. This approach allows for more experimentation and may ultimately allow for a more custom tailored solution (especially helpful for individuals with sensitivities to individual shampoo components).

Author's Experience
My own experience with tee tree oil was both limited and diverse. The limited part was related to my lack of progress with the various pre-made formulas tested. The diverse component stems from the fact that my testing involved numerous formulas and customized approaches with the pure essential oil (diluted). Unfortunately, I was never able to obtain any significant progress with tea tree oil, but the all-natural allure and the possibility for relief were hard to resist.

Other anti-fungals

There are numerous alternate antifungal agents with proven effectiveness against various malassezia yeast species. Some of these are not commonly prescribed in North America, while others have been replaced with new more effective counterparts.

Discussion of every single option is outside the scope of this article. However, three additional options that may be worth trying are provided.

Piroctone olamine
Nystatin

Originally called fungicidin, nystatin is considered the first successful anti-fungal agent ever produced [42]. It was the result of the work of a biochemist by the name of Rachel Fuller Brown and a microbiologist Elizabeth Lee Hazen, who isolated the substance from the defense mechanism of the streptomyces noursei bacteria [43].

Since it’s discovery, it’s broad spectrum antifungal activity has been utilized in a wide range of applications and treatment solutions.

Despite its long history of use, it’s popularity in seborrheic dermatitis treatment remains limited and it is not commonly prescribed by medical professionals. This may be partially explained by the existence of nystatin resistant strains of malassezia yeasts [44] and/or by it’s lower minimum inhibitory activity as compared to more recent azole antifungals such as ketoconazole and clotrimazole [45].

Whatever the case may be, nystatin has been documented to be an effective treatment for seborrheic dermatitis [46, 47] and numerous readers of this site have reported it being effective in cases where other antifungal agents have failed (see the Nystatin A Potential Seborrheic Dermatitis Treatment for more on this).

Unfortunately, topical nystatin formulations are primarily in cream/ointment form, making it unpractical for scalp application. However, if you’ve been dealing with seborrheic dermatitis that hasn’t responded to other topical agents, it may still be worth considering.

Salicylic acid

Salicylic acid is a benzoic acid derived from the willow tree. While it does possess some antifungal properties [48], it is not officially recognized as an effective anti-fungal agent against malassezia yeasts.

Regardless, it is considered an accepted anti-dandruff treatment and has been noted to reduce seborrheic dermatitis symptoms [49].

Unfortunately, there is no evidence that suggests it can fully eliminate seborrheic dermatitis symptoms if used on its own. Accordingly, it’s often used together with an active antifungal agent in an effort to improve treatment outcome [50, 51].

In relation to seborrheic dermatitis, the primary mode action is believed to be related to its keratolytic properties (softening the top layer of skin), allowing for more effective removal of skin flakes and improved sebum flow.

Some popular standalone salicylic acid (at 3% concentration unless otherwise noted) shampoos that could be worth a try include:

  • Neutrogena T/Sal Therapeutic Shampoo
  • Dermarest Psoriasis Medicated Shampoo Plus Conditioner
  • Avalon Organics Anti-Dandruff Itch & Flake Shampoo – 2% Salicylic Acid
  • MG217 Psoriasis Shampoo and Conditioner
  • Denorex Extra Strength Dandruff Shampoo and Conditioner
  • DHS SAL Shampoo

Alternatively, here’s a shampoo that combines salicylic acid with a secondary antifungal:

  • JASON Dandruff Relief Treatment Shampoo (Sulfur)

In theory, the combination of active ingredients should prove to be more effective (it even contains apple cider vinegar), but the Amazon reviews do not reflect this.

Salicylic acid shampoos may not be sufficient enough on their own in agressive cases, some have noted significant symptom relief in mild cases of seborrheic dermatitis

Author's Experience
In my experience, a simple salicylic acid shampoo such as Neutrogena T/Sal is rarely enough to relieve persistent seborrheic dermatitis issues. However, if issues are transient (come and go from time-to-time) and less aggressive, significant relief can be achieved.

Home remedies

The 21st century saw the rise of antibiotic-resistant bacteria, leading many individuals in search for natural alternative treatment options.

When it comes to seborrheic dermatitis, things aren’t much different. Even though it’s a condition more closely related to fungi, a sub-set of individuals do not respond to conventional therapy or simply reject the use of pharmaceutical medication.

As a result, natural treatment approaches have become quite popular and some of which have shown significant potential.

Apple cider vinegar

If you’ve ever looked online for a home remedy to scalp seborrheic dermatitis you’ve probably come across the use of apple cider vinegar washes and rinses. And as it stands today, this is probably the single most popular scalp seborrheic dermatitis home remedy that exists.

Strangely, the medical literature on the subject remains limited. There are a few papers that mention a 50/50 water-vinegar solution as being effective for treatment in dogs [52], but really that’s about it.

In theory, since a low pH level can inhibit some malassezia species [53], the low pH environment created by the application of apple cider vinegar may explain it’s reported effectiveness. But such method of action would mean that practically any vinegar would be suitable and the focus specifically on apple cider vinegar unwarranted.

Despite the lack of evidence, apple cider vinegar remains one of the most popular home remedies for scalp seborrheic dermatitis

Nonetheless, the single most popular vinegar treatment choice for scalp seborrheic dermatitis remains:

  • Braggs Apple Cider Vinegar

Braggs was one of the pioneering companies that made apple cider vinegar consumption popular with it’s Bragg Apple Cider Vinegar Miracle Health System book (unfortunately the book contains quite a bit of misleading information).

Alternatives exist and you’re likely to find many local producers in your own area as well (at health shops or specialty produce stores). And as noted earlier, you may even get away with almost any type of vinegar (if the effectiveness is solely attributed to the impact on skin pH).

Author's Experience
My own experience with apple cider vinegar was ultimately poor. Though it did produce some improvement of flaking and build-up, the results were inconsistent and it left the skin quite raw.

Further Reading
For more information on the use of apple cider vinegar, please refer to a previously written post: Treating Seborrheic Dermatitis With Apple Cider Vinegar

Raw honey

Throughout history, honey has been used for a variety of skin ailments and its use in modern skin care is substantial [54].

When it comes to skincare, honey has been shown to [55]:

  • Improve wound healing time
  • Prevent infection
  • Retard wrinkle formation
  • Regulate skin pH

Accordingly, it’s not surprising that researchers decided to investigate its use and potential for the treatment of seborrheic dermatitis.

Raw honey, also known as crude honey, is essentially honey that has not been fully filtered and still contains an abundant amount of natural waxes.

The most commonly quoted/referenced study implemented a 50/50 mixture of raw honey and water with significant improvements for the majority of study participants [56]. Most notable was the finding that maintenance application, post symptom clearance, resulted in drastically improved remission times and long-term effectiveness.

In support of this study, many online reports have also noted significant improvement with the raw honey treatment approach.

Is raw honey really superior to filtered honey?
There really is no clear answer. Some suggest the quality of honey and the specific pollinating plants are more important factors due to their relationship to its antibacterial properties [57]. Others suggest that the anti-inflammatory properties of wax need to be considered [58].

The biggest barrier to this approach is the difficulty of consistent application (honey quality can differ dramatically) and effort required for each treatment (application of honey for several hours to the affected skin, multiple times a week). The second of these being further amplified for scalp treatment; as the presence of hair makes it far more difficult to effectively apply the honey mixture directly to the affected skin.

Raw honey has documented effectivness for seborrheic dermatitis, but scalp treatment remains difficult

Being a ubiquitous product, you should be able to find numerous varieties of raw honey at your local supermarket or farmers market. If you’re feeling extra adventurous, you can look-up a local bee-keeper and connect with them directly (ensuring the freshest honey).

Due to the natural variation of honey, there is likely to be a proportional amount of variation in its effectiveness; making it difficult to recommend any specific kinds of honey.

Author's Experience
My own experience with honey for facial seborrheic dermatitis was overall quite positive and it was most likely the best homey remedy attempted. However, as it was simply too daunting to apply the honey mixture to the scalp, my experience with scalp usage is nonexistent.

Further Reading
You can find additional disucssion of this approach in the earlier Basics of Treating Seborrheic Dermatitis with Raw Honey article and the dedicated Raw Honey eBook section.

Dead sea salt

Exceptionally high in magnesium content, dead sea salt has been reported to be helpful in numerous skin issues and diseases.

Dead sea salts beneficial effects on skin issues have so-far been attributed it’s ability to [59]:

  • Improve barrier function
  • Reduce inflammation
  • Enhance hydration

And since these factors play substantial roles in the majority of skin issues, it’s easy to see why dead sea salt has gained such popularity.

When it comes specifically to seborrheic dermatitis, there is limited evidence for its use. Apart from numerous online/anecdotal reports that claim it can provide significant relief, there are no studies which evaluate its effectiveness.

If we shift our focus on to psoriasis, a condition similar to seborrheic dermatitis, the use of dead sea salt does appear to have some merit [60, 61]. With the most notable improvements seen with the use of climatotherapy (actually going to the dead sea to get the combined benefit of low altitude UV rays and magnesium-rich water bathing) [62, 63].

Assuming the anecdotal reports are authentic and benefits seen in psoriasis carry over to seborrheic dermatitis, giving dead sea salt a try may be worthwhile.

If your symptoms respond, you’ll have an inexpensive and easy way to deal with your scalp seborrheic dermatitis. If not, you can still use the salt at bath time for a more therapeutic experience.

Even with limited dead sea salt treatment may still be worth trying

You can find dead sea salt in most supermarkets nowadays. But if you’re looking for more variety you can always shop online (and even get it delivered directly from the dead sea itself).

Author's Experience
My own experience, with dead sea salt, was primarily in its use for my facial seborrheic dermatitis. Here, the results came rapidly and the ease of treatment was hard to rival. Unfortunately, remission did not last and the symptoms returned rapidly.

Anti-fungal conditioners

While anti-fungal (anti-dandruff) shampoos remain the primary treatment approach for the scalp seborrheic dermatitis, switching to an ordinary shampoo together with an anti-fungal conditioner may be worth a try.

It’s possible that the benefits of treating seborrheic dermatitis with an anti-fungal shampoo are partially offset by the irritation and microinflammation introduced by the surfactants (cleaning agents) used. Since most common anti-dandruff shampoos utilize the same/similar surfactant base, switching to a more gentle shampoo (using surfactants with lower irritation potential) might resolve this remaining component of your symptoms.

Additionally, since conditioners are designed for better penetration and residual effects, the anti-fungal agents may have more time to do their work (even though the active anti-fungal agent is usually used at a lower concentration in conditioner formulas).

Taken together these two factors may lead to improved treatment outcomes and longer remission periods.

The most popular zinc pyrithione conditioners come from Head and Shoulders. They have a number of formulas available, but their availability likely varies from store to store. From a quick review, the two that stood out most to me were:

But alternate options from other companies are also available:

  • Dr Marder’s A-D Psoriasis & Zinc Pyrithione Conditioner
  • Mane’n Tail Pyrithione Zinc Anti-Dandruff Conditioner
  • Mizani Scalp Care Conditioner
Anti-dandruff conditioners may present a more gentle treatment approach to scalp seborrheic dermatitis

For further optimization of this approach, co-washing may be considered. Co-washing is hair washing/cleansing approach that relies solely on the use of a conditioner, removing the need for a shampoo altogether. This approach has been gaining popularity in recent years and even Head and Shoulders have released a co-wash formula that includes zinc pyrithione:

Switching to the conditioner washing (co-wash) method pay further stabilize barrier function and lead to more lasting symptom relief

Though medical literature comparing the effectiveness of such a co-wash conditioner to a regular anti-dandruff shampoo does not exist, based on the known pathology seen in scalp seborrheic dermatitis, such an approach may ultimately prove superior; thanks to it’s reduced chance of barrier disruption.

Scalp barrier repair solutions

The three primary components of seborrheic dermatitis were introduced earlier in this article. One of these was the potential role of barrier abnormalities in symptom progression.

Theoretically, if adequate barrier function was maintained, skin irritants (malassezia and oleic acid) would not interact with lower layers of the epidermis (outer layer of skin) and the inflammation-driven immune response would be eliminated. In this scenario, the focus is not on eliminating the irritants altogether but improving the skin defense mechanism to such irritants.

In comparison to an antifungal approach that aims to reduce the number of irritants on the skin surface, focus on barrier repair minimizes the chance of these irritants triggering symptoms.

Literature evaluating the effectiveness of such an approach is extremely limited. The only study that I’ve seen used a simple glycerin-based moisturizing scalp gel designed to improve barrier function. The outcome was that the gel lead to a significant improvement of dandruff and reduction in symptom severity [64].

Nonetheless, from personal experience, I strongly believe that focus on improving and maintaining adequate barrier function can lead to a better outcome then focusing solely on antifungals.

For general seborrheic dermatitis, this can be achieved through the use of various barrier repair creams/ointments designed for eczema. However, for scalp seborrheic dermatitis things are a little trickier; as there is a lack of products that are specifically formulated for hair/scalp use.

From what is available, finding a gentle shampoo (with similar design methodologies to cleansers designed for sensitive skin) seems like a suitable middle ground. This alone may eliminate the microinflammation caused by some of the more common surfactants and lead to gradual symptom relief (as the barrier begins to stabilize).

Specific gentle shampoos that have been mentioned by community members include:

  • Free & Clear Shampoo for Sensitive Skin
  • Puracy Natural Shampoo
  • Maple Holistics Hydrate Moisturizing Shampoo
  • Nurture My Body All-Natural Everyday Shampoo
  • Jason Fragrance-Free Shampoo
  • Earth Science Fragrance-Free Shampoo
  • Aveeno Pure Renewal Gentle Shampoo
Switching to a gentle shampoo may eliminate a source of microinflamattion; leading to stable barrier function and gradual remission of symptoms

Author's Experience
For a period of nearly two years, I had used the Andalou Moisture Rich formula and it had provided me with significant relief (better than most antifungal solutions I had tested). Apart from the lack of dandruff, the other benefit was the scalp felt generally healthier (no scalp tightness reported with antidandruff shampoos). Unfortunately, the manufacturers changed the formula and the new one resulted in a return of my scalp issues.

Additional Items to Consider

Regardless of the treatment approach you take, there are other factors which can contribute to treatment outcome.

Longer Application Time Can Improve Outcome

Increasing the amount of time the shampoo is left on the scalp/hair has been shown to improve the effectiveness and treatment outcome [65].

This effect is not uniform across all anti-fungal agents. For example, the effectiveness of piroctone olamine is improved significantly more with extended exposure time, as compared to ketoconazole where the effect is not as drastic. Nonetheless, even with ketoconazole, an improvement was noted.

On the other side of this, is the possibility of surfactants to induce barrier disruption/permeability with prolonged exposure time [66].

It would be interesting to see what the impact of longer exposure times would be over a longer period of time (the first study mentioned was conducted over a period of only 3 days).

Reducing Water Temperature to Minimize Irritation

If you’ve been following along, you should now know that an integral part of seborrheic dermatitis progress is diminished skin barrier function and increased skin sensitivity. Accordingly, a competent barrier function is an integral part of symptom relief.

Since skin surfactants (primary skin cleansing agents) are considered “some of the most damaging of all substances routinely applied to the skin” you may literally being offsetting progress at each hair washing.

While reducing the number of times you shampoo is not always possible, finding ways to reduce the severity of irritation can be worthwhile.

One way to achieve this through the use of lower temperature water during the washing process [67]. So, next time you go to wash your hair, considering reducing the temperature and washing with cold water.

Authors Opinion and Commentary

Seborrheic dermatitis is a skin condition I never really knew I had until it spread beyond my scalp and started affecting my face. When it was restricted to the scalp, I didn’t give it much thought and simply understood it to be dandruff – which most people experience.

Once the condition started taking over my face, my life changed and I had become consumed. This nearly destroyed my social life and lead to many depressing nights at home.

It was only after several years of trying different solutions, I finally started to see progress and eventual remission of most of my symptoms. Nonetheless, my interest in what caused the condition to surface in the first place remains.

Though my understanding of seborrheic dermatitis continues to evolve, there are several systemic issues which I strongly believe play a role in the condition:

  • Metabolic issues (specifically in the metabolism of fats)
  • Lifestyle factors (sunlight exposure, geographical location, stress)
  • Diet (what, when, and how much)
  • Hormonal (pregnancy, medication)
  • Disease states (infection, auto-immune disorders)

While specific aspects play a bigger role for some and a smaller role for others, differing combinations of these factors are likely responsible for the initial emergence of dandruff and it’s eventual progression into it’s more severe form, seborrheic dermatitis.

At the foundation of all these issues, is their impact on immune system stability, levels of systemic inflammation, microbiota composition, and levels of lipid oxidation. All of which go on to produce an unstable skin microflora, impaired barrier function, and an over-reactive response to topical irritants.

Topical treatments can be extremely helpful in getting things under control, as they solve the physical symptoms of the condition and allow you to continue to live your life.

On the flip-side, if symptoms are controlled via topical means, but the underlying issues continue to progress underneath, you may see other health issues emerge down the line (other skin conditions, metabolic disease, etc). Thus, resolving the underlying issues that caused the condition in the first place is likely to lead to more long-term remission, while also improving your overall health.

This guide was an attempt to provide a basic gameplan for topical treatment. My ultimate goal is to provide a comprehensive examination of the underlying issues and possible ways to reverse them; this component of the discussion is expanded upon in the Seborrheic Dermatitis – The Owner’s Manual

Summary

Hopefully by the time you’ve finished reading this guide you’re left with a much deeper understanding of seborrheic dermatitis, how to approach treatment, and most importantly that it leads to eventual remission of your symptoms.

The guide has covered a lot of ground and it’s difficult to summarize all of the points discussed. Nonetheless, here is my attempt:

  1. Seborrheic dermatitis is a not fully understood, yet common skin condition that is restricted to sebum-rich areas of skin (such as the scalp, face, etc)
  2. Dandruff and seborrheic dermatitis are often used interchangeably; considering seborrheic dermatitis as a more aggressive form of dandruff may be more correct
  3. The condition is believed to be caused by an interplay between the malassezia yeasts, sebum composition, and individual sensitivity
  4. Presence of hair can make scalp symptoms more difficult to manage and hair loss often emerges as an indirect consequence of the condition
  5. Anti-fungal agents such as zinc pyrithione, ketoconazole, selenium sulfide, coal tar, and tea tree oil are the most documented treatment approaches
  6. Scalp treatment primarily relies on shampoos and conditioners containing these anti-fungal agents – ointments and gels can be helpful for more aggressive cases
  7. Apple cider vinegar, raw honey, and dead sea salt are three of the most popular home remedies with many anecdotal reports available online
  8. Optimizing barrier function by switching to a more gentle hair washing regimen might prove worthwhile and eliminate the need for active treatment

In the end, we’re all in this together. If you have any first-hand experience in dealing with scalp seborrheic dermatitis that you would like to share or any question regarding any of the content above, please leave a comment below.

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