Irregular Appearing Scalp: Skin Conditions That Change How the Scalp Looks

This page covers changes in the scalp skin. For bumps, ridges and lumps you can feel on the skull, see irregular appearing scalp: bumps and bony irregularities.

How scalp conditions change its appearance

Dermatologists describe scalp changes by what they see. The pattern is often enough to point to the cause.

Common causes

Seborrheic dermatitis

The most common cause of a flaky, irregular scalp. Inflammation linked to an overgrowth of a normal skin yeast (Malassezia) produces greasy yellow or white flakes, mild redness and itch. It often extends to the eyebrows, beside the nose and behind the ears. In babies it is called cradle cap. See seborrheic dermatitis.

Scalp psoriasis

Around half of people with psoriasis have scalp involvement. Plaques are thicker, redder and sharper-edged than seborrheic dermatitis, with silvery scale, and often show beyond the hairline on the forehead, neck and around the ears. Check the elbows, knees and nails for other signs.

Tinea capitis (scalp ringworm)

A fungal infection, mainly in children. It causes round, scaly patches with hair breakage, black dots where hairs have snapped, and swollen glands at the back of the neck. A severe inflammatory form, called a kerion, forms a painful, boggy, pus-filled swelling. Tinea capitis needs antifungal tablets; creams alone do not reach the hair root.

Folliculitis

Infected or inflamed hair follicles produce red bumps and pustules. Causes include bacteria, yeast, shaving and tight hairstyles. See folliculitis.

Contact dermatitis

Hair dyes (especially PPD), fragrances and preservatives in shampoos can cause redness, itch and scaling, sometimes spreading to the forehead, ears and neck.

Conditions that can scar the scalp

These matter because hair lost to scarring does not regrow. Early treatment is the key.

• Lichen planopilaris: a form of lichen planus affecting hair follicles. Redness and scale around hairs, itching or burning, and spreading patches of shiny bald skin.
• Frontal fibrosing alopecia: a recession of the frontal hairline and eyebrows, mainly in women after menopause.
• Discoid lupus: red, scaly patches that leave scarred, discolored bald areas.
• Central centrifugal cicatricial alopecia: hair loss starting at the crown, most common in women of African descent.
• Folliculitis decalvans and dissecting cellulitis: pustules, nodules and tunnels leading to scarring.

Sun damage and skin cancer

A bald or thinning scalp receives a lot of sun. Actinic keratoses are rough, scaly spots that can turn into squamous cell carcinoma. Basal cell carcinoma, squamous cell carcinoma and melanoma all occur on the scalp and can be hidden by hair. Any new, growing, bleeding or non-healing lesion needs a check.

How the cause is diagnosed

A dermatologist examines the whole scalp, hair, nails and skin elsewhere, and often uses a dermatoscope (magnifying light) to look at the follicles. Tests include:

• skin scrapings and hair plucks for fungal microscopy and culture
• swabs for bacteria
• a scalp biopsy for scarring alopecia, lupus and suspected cancer
• blood tests for lupus or other systemic conditions when relevant

Treatment

• Seborrheic dermatitis: antifungal shampoos with ketoconazole, selenium sulfide, zinc pyrithione or ciclopirox, used 2 to 3 times a week, plus short courses of steroid lotions for flares.
• Psoriasis: coal tar or salicylic acid shampoos to lift scale, steroid or vitamin D scalp solutions, and systemic or biologic treatment for severe disease.
• Tinea capitis: antifungal tablets such as griseofulvin or terbinafine for 4 to 8 weeks, plus antifungal shampoo to reduce spread. Check family members.
• Folliculitis: antiseptic washes and topical or oral antibiotics or antifungals.
• Scarring alopecias: steroid injections or creams, hydroxychloroquine and other anti-inflammatory medicines started early.
• Actinic keratosis and skin cancer: freezing, creams, photodynamic therapy or surgery.

Wear a hat and use sunscreen on exposed areas of the scalp.

Frequently asked questions

What causes an irregular appearing scalp?

The most common causes are seborrheic dermatitis, psoriasis, fungal infection (tinea capitis), folliculitis and contact dermatitis. Less common but important causes include scarring hair-loss conditions, discoid lupus, sun damage and skin cancer.

How do I tell scalp psoriasis from dandruff?

Dandruff and seborrheic dermatitis cause fine, greasy, yellowish flakes with mild redness. Psoriasis causes thicker, silvery scale on sharply defined, raised red plaques that often extend beyond the hairline. Psoriasis elsewhere on the body or nail pitting supports the diagnosis.

Can scalp patches cause permanent hair loss?

Most do not. Dandruff, psoriasis and ringworm usually allow hair to regrow after treatment. Scarring conditions such as lichen planopilaris and discoid lupus destroy follicles, so lost hair does not return. Early diagnosis limits the damage.

When should I see a dermatologist about my scalp?

See a dermatologist for bald patches with shiny or scarred skin, scaling that does not improve after 4 to 6 weeks of medicated shampoo, a painful swollen patch, or any growth or sore that bleeds or does not heal.