Particularly in the active phase, the disease may cause itching and sensitivity.
Scarring alopecias
Bald patches
At first erythema and scaling; may cause itching and pain
Individual lesions
When a new, obscure lesion appears or a lesion becomes ulcerated or does not respond to treatment, a skin biopsy should be taken to exclude malignancy.
Samples for microscopy and fungal culture are required if ringworm is suspected.
Rapid methods based on nucleic acid amplification are also available. The dermatophyte nucleic acid test identifies the most common dermatophytes. The indications for use in scalp ringworm are not yet established and the diagnostic benefits are unclear.
In seborrhoeic eczema, Malassezia yeast may be seen on microscopy but fungal culture may still be negative. The diagnosis should be based on clinical features.
Bacterial culture, as necessary, if the response to empirical antimicrobial treatment of impetigo or folliculitis is poor or resistance is suspected.
Epicutaneous tests may be indicated if allergic contact dermatitis is suspected.
If rare skin disorders (such as lichen planopilaris) or malignant skin lesions are suspected, histological examination of a skin biopsy is necessary.
Treatment
Treatment is presented in the specific articles for each skin disorder.
Causal treatment, if possible (such as less dyeing of the hair and other procedures on the scalp in patients with irritant contact dermatitis)
In seborrhoeic eczema, intermittent daily washing of the scalp with a ketoconazole shampoo and maintenance treatment by such washing twice a week, as necessary, usually helps Seborrhoeic Dermatitis in the Adult. Cyclopirox olamine or zinc pyrithione shampoo may also be used (over-the-counter products).
Thick crust can be softened and removed before washing by skin oil and topical salicylic acid treatment, as necessary.
Salicylic acid is normally used as a 5-10% extemporaneous mixture with a cream, castor oil or macrogol ointment base.
Rub the product on the scalp in the evening and wash it away in the morning. The period of treatment required varies from a few days to 2-3 weeks. Efficacy can be improved by wearing a hood or a cap.
In atopic eczema, additional topical treatment with a non-medicated ointment may help. Rub the non-medicated aqueous cream on the scalp in the evening and wash it away in the morning Atopic Eczema (Atopic Dermatitis) in Adults.
For neurodermatitis (usually on the neck), intermittent treatment with high to superpotency glucocorticoid solutions or ointments in courses of 3-4 weeks, for example, is needed.
Systemic antifungal medication is usually needed for the treatment of scalp ringworm Dermatomycoses.
For folliculitis, topical antimicrobial (e.g. clindamycin) solution, a mid- to high potency glucocorticoid solution or a combination solution with glucocorticoid and keratolytic agent twice daily intermittently in courses of 2-4 weeks, for example. Extensive and severe forms of disease may require systemic antimicrobial treatment with 500 mg cephalexin 3 times daily or flucloxacillin 750 mg 3 times daily for a total of 7-10 days, for example Skin Abscess and Folliculitis.
Specialist consultation
A dermatologist should be consulted in cases of severe scalp eczema resistant to treatment.
If allergic contact dermatitis is suspected, epicutaneous tests should be performed under the supervision of a dermatologist.
References
Hald M, Arendrup MC, Svejgaard EL ym. Evidence-based Danish guidelines for the treatment of Malassezia-related skin diseases. Acta Derm Venereol 2015;95(1):12-9. [PubMed]
Yew YW, Thyssen JP, Silverberg JI. A systematic review and meta-analysis of the regional and age-related differences in atopic dermatitis clinical characteristics. J Am Acad Dermatol 2019;80(2):390-401. [PubMed]
Schlager JG, Rosumeck S, Werner RN ym. Topical treatments for scalp psoriasis: summary of a Cochrane Systematic Review. Br J Dermatol 2017;176(3):604-614. [PubMed]