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Scalp problems in the pharmacy shampoo
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Continuing professional development
Scalp problems in the pharmacy
Christine Clark looks at scalp conditions, including dandruff and hair loss
he scalp covers the top of the head and
T comprises five layers of tissue, the first
letters of which conveniently spell scalp:
■ Skin Skin contains hair follicles, sweat
glands, many sebaceous glands, arteries,
and veins. The skin of the scalp is rela-
tively thick and is usually hairy.
■ Connective tissue Connective tissue
Viewing Medicine
contains dense fibrous and fatty tissue,
arteries, veins, lymphatic vessels and cuta-
neous nerves. Wounds that penetrate this
layer tend to bleed profusely because the
dense tissue does not retract and close Mild seborrhoeic
blood vessels in the way that other tissues dermatitis
do.
■ Aponeurosis The aponeurosis is a thin Identify knowledge gaps
(1–2mm thick) tendinous layer. 1. Can you list three active ingredients commonly
■ Loose areolar tissue Loose areolar found in anti-dandruff products and how they
tissue connects the aponeurosis to the work?
pericranium. It is predominantly vascular. 2. How is tinea capitis treated?
■ Pericranium The pericranium is the 3. What are the treatment options for hair loss?
tissue enveloping the bones of the skull.
Before reading on, think about how this article may
Pharmacists are often asked for advice on help you to do your job better. The Royal
Viewing Medicine
itchy scalps. Common causes include sebor- Pharmaceutical Society’s areas of competence for
rhoeic dermatitis, contact dermatitis, psoriasis pharmacists are listed in “Plan and record”,
(PJ, 21 May 2005, pp622–6), head lice (to be (available at: www.rpsgb.org/education). This
covered in an article later this year) and tinea article relates to “common disease states” (see
capitis (scalp ringworm) and, in many cases, Moderate to severe appendix 4 of “Plan and record”).
various treatments can be recommended. seborrhoeic dermatitis
Some people, however, simply suffer from
a dry itchy scalp, which can be influenced by — it is confined to areas that are rich in seba-
diet, general health and season. In such cases, ceous glands (the scalp, the nasolabial folds
pharmacists can give general advice, such as [the crease that runs from the nose to the
switching to a milder shampoo (eg, a baby corner of the mouth], the ears, eyebrows and
shampoo) and washing the hair less eyelashes, the chest area in front of the ster-
frequently. num, and between the shoulders on the back).
For many people, loss of hair or other The lesions are covered with greasy-looking
visible scalp conditions can cause immense scales and there may be some crusting. The
distress, and sensitivity is required when deal- underlying skin can be itchy, red and sore.
ing with these problems. Differential diagnoses include atopic eczema
and scalp psoriasis.
Dandruff and seborrhoeic dermatitis Seborrhoeic dermatitis occurs in at least 3
Dandruff, seborrhoeic dermatitis and cradle per cent of the population. It is more common
cap are all part of the same disorder but they in men than in women and in people with
vary in severity and when in life they appear. neurological conditions (eg, Parkinson’s dis-
Dandruff occurs in up to 80 per cent of ease and stroke) or HIV infection. In adults,
teenagers and adults and most people are the condition fluctuates in severity and can
familiar with the symptoms — a scaling scalp persist for years. Seborrhoeic dermatitis occurs
that sheds fine, white or grey flakes of dead as cradle cap in infants under the age of eight
skin. These are often seen in the hair, close to months (see Panel 1, p432) but is rarely seen
the scalp, and are visible on the collars and between infancy and puberty.
shoulders of dark clothing. Some textbooks The exact cause of seborrhoeic dermatitis
use the term “pityriasis capitis” (bran-like is unknown but it is strongly associated with
scale of the scalp). the presence of malassezia yeasts (previously
In seborrhoeic dermatitis there is a greater known as Pityrosporum ovale). These are found
degree of scaling and other body areas can be in large numbers in sebaceous gland rich areas
affected. Dandruff can be the first sign of of all adults. One hypothesis is that the inflam-
seborrhoeic dermatitis, but in many cases it Christine Clark, PhD, matory reaction is caused by the proliferation
does not progress to anything more serious. FRPharmS, is a freelance of the yeast, which is able to metabolise some
Seborrhoeic dermatitis is an inflammatory writer and pharmaceutical components of sebum. An alternative hypoth-
skin disease with a characteristic distribution consultant esis suggests that there are normal levels of
www.pjonline.com 14 April 2007 The Pharmaceutical Journal (Vol 278) 431
malassezia but an abnormal immune response the hair. Seborrhoeic dermatitis affecting the
in the host. Reduction in the yeast population
is associated with improvement or elimination
Panel 1: Cradle scalp and beard area can be treated with
shampoos. However, if other areas of the body
of the condition. cap are affected, ketoconazole cream is the treat-
Seborrhoeic dermatitis is not contagious or Cradle cap is a patchy, greasy, ment of choice.
related to diet, but it may be aggravated by scaly and crusty skin rash that Patients using selenium sulphide shampoo
illness, psychological stress, fatigue, change of occurs on the scalp of recently should be advised not to apply it for 48 hours
season and reduced general health. Various born babies. It is, in effect, before or after colouring their hair or using
medicines can worsen or induce seborrhoeic infantile seborrhoeic hair-waving or straightening agents. Those
dermatitis, including buspirone, chlorpro- dermatitis that is confined to with light, grey or chemically treated (eg,
mazine, cimetidine, gold, griseofulvin, the scalp. Seborrhoeic bleached, tinted, permanent-waved) hair,
haloperidol, interferon alfa, lithium, methyl- dermatitis can also affect should be advised to rinse their hair for at
dopa, phenothiazines and psoralen. other areas of the body, such least five minutes after shampooing to lessen
as behind the ears, in the the chance of discoloration.
Treatment The treatment of dandruff and creases of the neck, armpits If the inflammation is severe, short-term
mild seborrhoeic dermatitis is similar and an and napkin area. use of a topical corticosteroid can be helpful.
extensive range of products is available over Crusting and scale can be This controls the inflammation more quickly
the counter for topical use. Active ingredients removed by gentle brushing than an antifungal alone. It is important to re-
include zinc pyrithione, selenium sulphate, with a soft brush or by mind patients to discontinue the steroid
ketoconazole, coal tar, salicylic acid, and an- massaging with olive oil to within 14 days (or as soon as an acceptable
timicrobial detergents (eg, cetrimide). Some of soften and loosen the scale improvement is achieved) but to continue
these ingredients are present in general then shampooing normally with the antifungal treatment. Corticosteroids
toiletries (eg, Head & Shoulders contains zinc with any baby shampoo. One have no effect on the fungal population.
pyrithione) so pharmacists should ask what health visitor has Steroid scalp applications listed by Prodigy for
shampoos have already been used. The effec- recommended massaging the treatment of seborrhoeic dermatitis
tiveness of zinc pyrithione, selenium sulphide Epaderm into scalp, leaving it include betamethasone, hydrocortisone bu-
and ketoconazole appears to be linked to their on overnight and washing it out tyrate and mometasone furoate. Clobetasol
antimicrobial (ie, antifungal) action whereas in the morning (no shampoo is propionate is considered too potent and not
coal tar and salicylic acid are keratolytics — needed). recommended.
they encourage the shedding of dead skin. However, in most cases Panel 2 lists further advice pharmacists can
Products containing zinc pyrithione or coal cradle cap resolves give.
tar products, or both, can be recommended as spontaneously by the age of
first-line treatments for dandruff or mild cases eight months and pharmacists Tinea capitis
of seborrhoeic dermatitis. Directions differ, can reassure anxious parents Scalp infections are the most common der-
but shampoos are usually used twice a week of this. The cause of cradle cap matophyte infections in children worldwide.
for two weeks to bring the symptoms under is not clearly defined but it is Scalp ringworm (tinea capitis) is a superficial
control (this can take up to four weeks with not caused by infection, allergy fungal infection that mainly affects children
ketoconazole) then less frequently, as necessary or poor hygiene. and is rare in adults.The infection is caused by
for prophylaxis. The lather should be left on Occasionally, severe cases various dermatophytes, spore-forming fungi
the scalp for a few minutes before rinsing. of cradle cap can distress the that can invade and ingest keratin-rich tissue.
Scalp ointments can be used daily for the first infant and may warrant The fungi invade deep into the stratum
seven days. They are applied and shampooed treatment with an antifungal corneum (the outermost layer of skin) or
off after one hour. (ketoconazole) shampoo or other keratinised skin appendages derived
The degree of scaling and inflammation cream. from epidermis, such as hair and nails. They
can vary between patients. For moderate to can, however, also be carried on the scalp
severe seborrhoeic dermatitis, ketoconazole 2 without invading the skin or hair. One study
per cent shampoo or products containing in schools in south London revealed a tinea
selenium sulphide can be recommended first capitis prevalence of 2.5 per cent and a
line. Ketoconazole is generally better tolerated carriage rate of 4.9 per cent. Infections are
and it may be marginally more effective. The more common in boys than in girls.
recurrence rate of the disease is lower after Two types of dermatophyte are associated
ketoconazole treatment and this is presumed with tinea capitis: anthropophilic (transmitted
to be because the antifungal accumulates in between humans) and zoophilic (transmitted
from an animal host). In the UK and North
America the most common causative organ-
Products for dandruff or seborrhoeic dermatitis ism is now Trichophyton tonsurans. Micro-
sporum species are the second most common.
Keratolytics Antifungals Combination products The prevalence of tinea capitis is increasing in
■ Coal tar ■ Ketoconazole Capasal shampoo (coal tar the UK, particularly in urban areas and
Alphosyl 2 in 1 shampoo Dandrazol shampoo, + salicylic acid), Cocois among children of Afro-Caribbean origin.
Clinitar shampoo, T/Gel Nizoral shampoo scalp ointment (coal tar + This is believed to be due to anthropophilic
therapeutic shampoo, salicylic acid), Polytar AF spread of T tonsurans. A factor that might
Pentrax shampoo, Polytar ■ Selenium sulphide shampoo (coal tar + zinc contribute to the spread is that the organism
liquid, Psoriderm scalp Selsun shampoo pyrithione), Sebco scalp remains viable on combs, brushes, furniture
lotion ointment (coal tar + and bed sheets for long periods.
■ Detergent based salicylic acid) In general, tinea capitis is characterised by
■ Salicyclic acid Betadine shampoo, Ceanel a round, bald, scaly patch on the scalp. The
Meted shampoo concentrate shampoo, hair can be broken in and around the patch,
Dermax shampoo leaving 3–4mm stumps. Scalps infected with
zoophilic species are usually more inflamed
432 The Pharmaceutical Journal (Vol 278) 14 April 2007 www.pjonline.com
Continuing professional development
Continuing professional development
than those infected with anthropophilic cia. Although it is also called male-pattern
species. The first presenting symptoms will Panel 2: Advice baldness, it can affect women, occurring after
usually be small patches of scaly skin with a the menopause. White men are four times
little hair loss. Once the hair and hair shafts for patients with more likely to develop premature balding
are infected, they are weakened and can break sebhorroeic than black men. By the age of 30 years, 30 per
off below the hair shaft, giving the appearance cent of white men have androgenic alopecia
of black dots in the scalp. Patients in whom dermatitis and this increases to 50 per cent by the age of
scalp ringworm is suspected should be ■ Seborrhoeic dermatitis 50 years. About half of all women aged 50
referred to their GPs for tests (eg, microscopy cannot be cured but the years or over will have some degree of the
and culture of skin scrapings) and antifungal condition can be improved condition, usually seen as a diffuse thinning
therapy. and controlled over the crown of the head. The usual pattern
■ Relapse after treatment is in men is for hair to be lost over the temples
Treatment Tinea capitis must be treated common before spreading to the crown.
with systemic antifungal agents because topi- ■ Dense scaling can Androgenic alopecia is an inherited condi-
cal agents cannot penetrate all the infected decrease the effect of tion caused by dihydrotestosterone (DHT). It
areas. The length of treatment is determined antifungals so a is believed that DHT reduces the blood sup-
by the time it takes for infected hair and skin keratolytic can be used to ply to hair follicles so individual hairs become
to grow out and this varies according to sea- remove scales before thinner, less pigmented and eventually fall
son. Treatment is deemed successful when antifungal treatment out. Drug treatment of androgenic alopecia,
culture of skin scrapings from the infected ■ An alternative to a aiming to reverse the effects of DHT, is avail-
area shows no growth of the organism keratolytic is to apply able but is not prescribable on the NHS. Two
involved. Systemic antifungal medicines in- warm olive oil to the scalp drugs are licensed: minoxidil and finasteride.
clude griseofulvin, itraconazole, ketoconzole, for a few hours and then
fluconazole and terbinafine. Griseofulvin is wash with normal Minoxidil Minoxidil can be purchased over
effective against T tonsurans and Microsporum shampoo the counter as a topical lotion, in concentra-
species. Oral ketoconazole and itraconazole ■ Antifungal shampoos can tions of 2 per cent (for men and women) and
are usually avoided because of the risks of sometimes dry the hair 5 per cent (for men only — the higher
liver toxicity and fluconazole is not licensed and a moisturising strength product can cause hirsutism in
for this indication. Oral terbinafine is not li- shampoo can be used women, at remote sites, such as the chin).
censed for use in children but there is wide immediately after or One millilitre is applied twice a day to the
experience of use for this indication and between applications dry hair and scalp. Minoxidil dilates arteries,
dosage instructions are given in the British ■ Alcoholic products (eg, increasing blood flow to the hair follicles.
National Formulary for children over the age hair tonics) can irritate Although less than 2 per cent of the applied
of one year. Treatment is usually for two inflamed areas dose is absorbed, patients with cardiovascular
weeks. ■ Soaps and shaving disease should be referred to their GPs before
Griseofulvin is the only licensed treatment creams can be irritating treatment.
for tinea capitis in children of one month and — emollients can be used Minoxidil can only restore existing hair
older. An oral daily dose of 1g for up to three as soap substitutes growth and cannot reactivate dead follicles.
months is indicated for adults and 15–20mg ■ Improvement should be Early treatment (when the bald patch is no
per kg for children under 50kg. (Note, this is seen within seven days of more than 10cm in diameter and still has
higher than the dose recommended by using a topical some residual hair), therefore, gives the best
Prodigy.) A suspension is available from corticosteroid results. About 40 per cent of patients will see
specialist importers. Griseofulvin has many ■ Some products contain some regrowth, which is rarely dense, within
side-effects that affect about 20 per cent of peanut (arachis) oil 12 months. Patients should be told that hair
patients. These include headache and growth is stimulated only for as long as the
gastrointestinal upset and, more rarely, photo- agent is used and baldness will quickly reoc-
sensitivity and lupus-like symptoms. It is cur if treatment is discontinued.
contraindicated in several circumstances in-
cluding severe liver disease and pregnancy — Finasteride Finasteride is an inhibitor of 5-
pregnancy should be avoided during and for alpha-reductase, the enzyme that metabolises
one month after treatment, and men should testosterone into DHT. It is an oral treatment
be advised not to father children within six that can only be prescribed for men. It is an
months of treatment. anti-androgen and, when prescribed to treat
Antifungal shampoos are believed to be male-pattern baldness, the dose is 1mg daily
useful when used in conjunction with sys- which will produce an effect after between
temic treatment to reduce transmission of the three and six months. Care should be taken to
disease through shedding of spores. For the ensure that there is no confusion between this
same reasons, some dermatologists recom- 1mg dose of finasteride (Propecia) and the
mend treating close contacts who may be 5mg dose (Proscar) which is indicated for be-
asymptomatic carriers. Suitable shampoos are nign prostatic hyperplasia. The rapid hair fall
those containing selenium sulphide, keto- seen with stopping minoxidil does not occur
conazole or povidone iodine. with finasteride but, if treatment is discontin-
ued, baldness will return within six to 12
Alopecia months.
Alopecia (hair loss) can be classified according
to whether it is diffuse or localised, and Other products A number of other products
whether or not there is associated scarring. are claimed to restore hair and treat thinning
Tinea capitis is hair, including Nourkrin, Foltene and
Androgenic alopecia Androgenic alope- characterised by a round, Silicium 44. Nourkrin is dietary supplement
cia is the most common type of diffuse alope- bald, scaly patch containing marine, derived polysaccharide
www.pjonline.com 14 April 2007 The Pharmaceutical Journal (Vol 278) 433
Panel 3: The normal hair growth cycle
Each follicle produces a number of hairs during a lifetime. There are
three phases of growth:
1. The anagen or growth phase on the scalp lasts between three
and five years and the hair grows at approximately 1cm a month.
The duration of the anagen phase varies between people and it Hair shaft Catagen phase
determines how long the hair will grow if not cut. Usually about 85
per cent of follicles are in the anagen phase.
2. The catagen phase follows the anagen phase. It is a transitional Sebaceous gland
Hair
stage, lasting two to three weeks during which growth stops follicle Arrector pili muscle
and the outer root sheath shrinks and attaches to the root of the
hair.
3. The telogen or dormant phase lasts about three months. The Dermal papilla (influences
hair remains in the follicle but does not grow. When the follicle re- epidermal cells to differentiate
to produce keratinised hair
enters the anagen phase and a new hair starts to grow, the old
fibre)
hair is pushed out. Between 25 and 100 telogen phase hairs are Anagen phase Telogen phase
shed each day.
and fish extract. One small placebo-con- scalp. In alopecia areata, hair growth usually
trolled trial (n=55) has shown that partici- stops in localised areas.The condition can also
pants taking the supplement for six months affect the beard area and eyebrows. Patients
had an average hair growth increase of 37.5 can be as young as their teens, and will have
per cent compared with 1.5 per cent in the sharply defined bald patches and so-called
placebo group. The researchers speculate that “exclamation-mark” hairs that are short
the action may be related to an effect on (0.5cm) and less pigmented than normal and
DHT. Foltene and Silicium 44 are both topi- that taper towards the scalp.
cal products. The former contains a patented Alopecia areata has an autoimmune origin
mixture of polysaccharides and it is unclear Action: practice and is fairly common. It is often associated
what the active ingredients in the latter prod-
uct are.There is little evidence for the efficacy
points with stress or emotional upheaval.The condi-
tion is unpredictable and various outcomes
of of these products. Reading is only one way to are possible. For example, the patches can
undertake CPD and the enlarge but regrowth of hair after a few
Other types of diffuse alopecia Diffuse Society will expect to see months is common. However, the new hair
non-scarring alopecia is associated with a various approaches in a can be white. If the condition reoccurs, more
variety of endocrine disorders. For example, pharmacist’s CPD portfolio. patches are seen, with a slower regrowth of
underactive thyroid, pituitary or adrenal 1. Some patients find coal tar hair. If alopecia areata occurs before puberty,
glands can cause the condition, as can an over- products unpleasant. Look the prognosis is poor. In extreme cases, all the
active thyroid.Women who are suffering from at keratolytic products hair can be lost from the scalp (alopecia
androgen-secreting tumours will also display with your staff. Which are totalis). Treatment of alopecia areata is not
male-pattern baldness with virilisation. the most pleasant and usually successful. Topical steroids and topical
Malnutrition can have a detrimental effect convenient to use? immunotherapy have been used with limited
on the hair. For example, when the diet lacks 2. Make sure you know the success. Minoxidil has also been used.
sufficient protein, the hair can become dry, directions for using Trauma to the hair and scalp can also
brittle and red or pale. Deficiencies of iron or treatments for seborrhoeic cause patchy hair loss. Causes include: rub-
zinc can also give rise to diffuse hair loss. dermatitis. bing or pulling the hair constantly, using tight
Telogen effluvium is another form of dif- 3. Look at the evidence for rollers, pulling the hair into a tight bun and
fuse alopecia. The telogen phase is the shed- the efficacy of dietary using chemicals to straighten, bleach or perm
ding phase of hair growth during which supplements and other the hair.
about 50 to 100 hairs are shed daily (see Panel products for hair loss. How
3).Telogen effluvium is a condition when, in- would you explain this to a Scarring alopecia In scarring alopecia
stead of the hair follicles being out of phase, customer? (cicatricial alopecia) hair follicles are de-
in response to an event (eg, high fever, child- stroyed. Hair loss can be diffuse or localised.
birth, surgery and some drugs) they become Evaluate Causes include chemical burns, thermal
synchronised so that many hairs are shed at For your work to be presented burns, irradiation, lichen planus, lupus ery-
the same time about three months after the as CPD, you need to evaluate thematosus and infections, such as shingles
event. Other drugs can cause an abrupt cessa- your reading and any other and tertiary syphilis. Again, minoxidil and
tion of hair growth (anagen effluvium). This activities. Answer the finasteride are not treatment options.
effect is well known with cytotoxics and, following questions:
more rarely, with heparin, warfarin, carbima- What have you learnt?
zole and colchicine. The hair usually begins How has it added value to your Further reading
to grow again if the drug is discontinued. practice? (Have you applied ■ Guidance on seborrhoeic dermatitis and fungal skin
There is no place for minoxidil or finas- this learning or had any infections is available from National Library for Health
teride in pathological hair loss. feedback?) What will you do Clinical Knowledge Summaries (http://cks.library.nhs.uk/)
now and how will this be Signposting
Localised alopecia When alopecia is achieved? ■ The Trichological Society (tel: 08707 666 996; website:
localised, hair loss occurs in patches across the www.hairscientists.org)
434 The Pharmaceutical Journal (Vol 278) 14 April 2007 www.pjonline.com
