Scalp Flaking: Causes and Treatment

Why the scalp flakes

Skin cells on the scalp are constantly replaced, normally in tiny, invisible amounts. Flakes appear when cells turn over too quickly or clump together because of inflammation, or when the skin dries and cracks. Most scalp flaking is harmless but can be itchy, embarrassing and persistent.

Common causes of scalp flaking

Dandruff

Dandruff is the mildest form of seborrheic dermatitis. White or yellowish flakes shed from the scalp onto hair and shoulders, often with mild itch. It is linked to an overreaction to Malassezia, a yeast that lives on everyone's skin and feeds on scalp oils. It is common from puberty onward, worse in winter and with stress, and not caused by poor hygiene, though infrequent washing makes flakes more visible.

Seborrheic dermatitis

Seborrheic dermatitis is the more inflamed form. Expect red patches with greasy, yellow scales on the scalp, often extending to the hairline, eyebrows, sides of the nose, behind the ears, beard and chest. It tends to come and go. It is more common and more severe in people with Parkinson's disease, HIV and some other conditions. In babies it is called cradle cap.

Dry scalp

Dry scalp produces small, white, dry flakes without redness or greasiness. Cold weather, indoor heating, hot water, frequent washing and harsh shampoos strip oils from the scalp. Dry skin elsewhere on the body is a clue.

Scalp psoriasis

Psoriasis often affects the scalp. It causes thick, raised, red plaques covered in silvery-white scales, with sharp edges, often extending beyond the hairline onto the forehead, neck or behind the ears. It can be very itchy. Psoriasis elsewhere (elbows, knees, lower back) or nail pitting supports the diagnosis.

Contact dermatitis

A reaction to hair dye (especially PPD), fragrances, preservatives or styling products causes an itchy, red, burning or flaky scalp, often at the hairline, ears and neck, within days of using a product.

Scalp ringworm

Tinea capitis is a fungal infection of the scalp and hair, most common in children. It causes scaly patches with broken hairs, patchy hair loss and sometimes black dots or swollen glands in the neck. It needs oral antifungal medicine because creams cannot reach the hair roots.

Dandruff vs dry scalp vs psoriasis

Treatment for a flaky scalp

Medicated shampoos

Use as directed on the label, usually 2 to 3 times a week. Massage into the scalp and leave on for 3 to 5 minutes before rinsing. If one stops working, switch to another active ingredient.

• Zinc pyrithione: reduces yeast and inflammation. A good first choice.
• Ketoconazole (1% OTC, 2% prescription): antifungal, very effective for dandruff and seborrheic dermatitis.
• Selenium sulfide: slows skin cell turnover and reduces yeast. It can discolor light or chemically treated hair.
• Coal tar: slows cell growth. Helpful for psoriasis. It can stain and has a strong smell.
• Salicylic acid: lifts and softens thick scale, useful in psoriasis.

Other measures

• Dry scalp: wash less often with a mild shampoo, use lukewarm water, and apply a light oil or leave-in conditioner.
• Thick psoriasis scale: apply an oil or salicylic acid preparation overnight, then wash out.
• Contact dermatitis: stop the product, and use a mild steroid scalp lotion short term. Patch testing can identify the allergen.
• Cradle cap: gently massage baby oil or petroleum jelly into the scales, brush gently with a soft brush, then wash with baby shampoo.

Prescription treatments

• steroid scalp lotions, foams or shampoos for inflamed seborrheic dermatitis and psoriasis
• vitamin D analogue scalp treatments for psoriasis
• oral antifungals for scalp ringworm, plus antifungal shampoo for household members
• systemic or biologic medicines for severe psoriasis

Frequently asked questions

How do I know if it is dandruff or dry scalp?

Dandruff flakes are larger, yellowish or white and often greasy, and the scalp may look oily or slightly red. Dry scalp flakes are small, white and dry, with no redness, and you often have dry skin elsewhere. Dandruff improves with antifungal shampoo, dry scalp with gentler washing and moisture.

What is the best shampoo for a flaky scalp?

For dandruff and seborrheic dermatitis, shampoos with ketoconazole, zinc pyrithione or selenium sulfide work best. For psoriasis, coal tar or salicylic acid shampoos help. Use them 2 to 3 times a week, leaving them on for several minutes, and rotate if one stops working.

Can stress cause a flaky scalp?

Yes. Stress can trigger or worsen flares of dandruff, seborrheic dermatitis and psoriasis. It does not cause them directly, but managing stress, sleeping well and keeping up with medicated shampoo can reduce flares.

When should I see a doctor about scalp flaking?

See a doctor if flaking does not improve after 4 weeks of medicated shampoo, if you have patches of hair loss, thick plaques, a painful, oozing or swollen scalp, or rash elsewhere on the body. Children with scaly patches and hair loss should be checked for ringworm.