Scalp Problems

Essentials

• Many common skin disorders can occur on the scalp.
• Their topical treatment on the scalp differs from that in other skin areas.
• It is important to recognize any irritating factors (hair dyes, hairdo, etc.)
• Other areas (other skin areas, nails, ears) should be examined because diagnostic signs may be found there.

Diagnosis

• The diagnosis is usually based on the patient history and clinical picture.
• Does the patient have any history of skin disorders, such as atopic eczema or psoriasis? Is there a family history of skin disorders?
• Check other areas (face, ears, other skin, nails, etc.).
• Does the patient have any diagnosed contact allergy? Has the patient reacted to, for example, hair cosmetics, fragrances, hair dyes or other products?
• Are there any irritant factors involved? Hair dyes, hair cosmetics, hairdo?
• Has any of the patient's contacts had ringworm or impetigo on the scalp or lice?

The most common causes

• Seborrhoeic eczema Seborrhoeic Dermatitis in the Adult (pictures )
  • Clearly defined diffuse erythema, scaling
  • Can often be seen in other areas, as well (e.g. in the ear area, on the face, upper trunk)
• Atopic eczema Atopic Eczema (Atopic Dermatitis) in Adults
  • Can usually also be seen in other typical areas
• Psoriasis Psoriasis (pictures )
  • May occur on the scalp, only, but lesions are usually also seen in other typical areas.
• Irritant eczema, irritant contact dermatitis (hair dyes, hair care products) Irritant Contact Dermatitis

Rarer causes

• Folliculitis Skin Abscess and Folliculitis (picture )
  • Inflammation of single hair follicles, erythematous papules or pustules
• Neurodermatitis (pictures )
  • On the scalp almost always on the neck
  • May be a chronic form of another skin disorder; vicious circle of itching and scratching
  • Contact allergy is possible
• Ringworm Dermatomycoses (picture )
  • The clinical picture may vary considerably, from slight scaling to deep abscesses.
  • May cause permanent hair loss.
  • More common in dark-skinned people, particularly in children
• Impetigo Impetigo and other Pyoderma
  • Usually unilateral, at first, and may then spread
  • Clearly defined, erosive surfaces covered by yellow crust
  • Usually few symptoms
• Lice Head Lice and Pubic Lice
  • Often involves secondary pyoderma resembling impetigo.
  • There may also be neck eczema and enlarged lymph nodes on the neck.
• Allergic contact dermatitis Allergic Contact Dermatitis
  • Acute, itchy rash
  • Find out whether any contact allergy has been diagnosed. Hair dyes or hair cosmetics?
• Rare autoimmune diseases may cause scalp symptoms and scarring alopecia.
  • Lichen ruber planus Lichen Planus (pictures )
  • Cutaneous lupus erythematosus (DLE Discoid Lupus Erythematosus; picture )
• Rare scarring types of folliculitis (perifolliculitis capitis, folliculitis decalvans, keloidal folliculitis, etc.)
  • Often resistant to treatment
• Hairdo or hair manipulation (may also lead to a type of hair loss called traction alopecia)
• Dysaesthesia of the scalp
  • No objective findings
  • Itching, tingling or a burning sensation
  • May be associated with psychiatric disease or persistent somatoform pain disorder
• Trichotillomania, hair pulling disorder (pictures )
  • Compulsive need to pull out one's hair; an obsessive-compulsive spectrum disorder

Hair loss

• See the article on hair loss and baldness Hair Loss and Balding.
• Some disorders causing hair loss may also cause symptoms on the scalp.
  • Alopecia areata (pictures )
    • Bald patches
    • 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.
  • Skin tumours typically occurring on the scalp:
    • Benign skin tumours: atheroma, seborrhoeic keratosis, pigmented naevus, lipoma, tricholemmoma, trichoepithelioma, naevus sebaceus (picture ), syringocystadenoma papilliferum (picture )
    • Actinic keratosis and carcinoma in situ (circumscribed scaly patches, usually on a man's scalp with no hair, no response to eczema treatments)
    • Malignant skin tumours: basal cell carcinoma (basalioma), squamous cell carcinoma, melanoma

Workup

• 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 eczematous diseases, the treatment of first choice is intermittent use of mild to high potency glucocorticoid solutions for 2-3 weeks, for example Topical Anti-Inflammatory Agents for Seborrhoeic Dermatitis of the Face or Scalp.
• 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 scalp psoriasis, use salicylic acid at first (see above). In addition, use mid- to high potency glucocorticoid solutions intermittently in courses of 3-4 weeks, for example. Combination products with glucocorticoid and calcipotriol Psoriasis or a shampoo containing potent glucocorticoid may also be used.
• 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.
• Impetigo on the scalp should be treated with antimicrobial drugs Impetigo and other Pyoderma.
• 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.

Pictures