As a pharmacist, people will ask you how to treat dandruff or cradle cap, the “infant version” of dandruff. Both are a form of dermatitis. Dandruff is chronic flaking and itching, often on the scalp and occurs in adults and adolescents. Cradle cap is scaly, greasy patches that rarely itch and usually clears up on its own by about 1 year of age.
For dandruff, start with an OTC shampoo with antifungal effects, such as pyrithione zinc 1% (Head & Shoulders Classic Clean, etc) or selenium sulfide 1% (Selsun Blue Moisturizing, etc). Lean toward ketoconazole 1% shampoo (Nizoral A-D, etc) instead for more severe symptoms, such as yellow, greasy, or thicker scales.
Generally advise using the product at least twice weekly for 2 to 3 weeks to start, then once weekly to keep symptoms at bay. Educate to massage shampoo into the scalp or other affected areas and leave on for about 5 minutes before rinsing. Explain that patients may need to alternate products every few months if one stops working, possibly due to resistant yeast.
If OTCs don’t do the trick, prescribe ciclopirox 1% or ketoconazole 2% shampoo. Consider adding a low-potency topical steroid (fluocinolone 0.01% solution, etc) for 2 to 4 weeks if needed for inflammation.
For cradle cap, reassure that treatment usually isn’t needed. If caregivers want to do something, suggest softening the scales by applying an emollient (petrolatum, etc), washing with baby shampoo and using a washcloth to gently remove them. For severe cases, use a cream or lotion, such as hydrocortisone 1% or ketoconazole 2%, these are more likely to “stay put” than shampoos.
Don’t rely on other topical remedies (aloe, tea tree oil, etc) for dandruff or cradle cap. There’s no good evidence of efficacy.
REFERENCES
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Borda LJ, Perper M, Keri JE. Treatment of seborrheic dermatitis: a comprehensive review. J Dermatolog Treat. 2019 Mar;30(2):158-169. Available at: https://www.tandfonline.com/doi/abs/10.1080/09546634.2018.1473554?journalCode=ijdt20
Victoire A, Magin P, Coughlan J, van Driel ML. Interventions for infantile seborrhoeic dermatitis (including cradle cap). Cochrane Database Syst Rev. 2019 Mar 4;3(3):CD011380. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011380.pub2/full
HealthyChildren.org. Cradle Cap. [online] Available at: https://www.healthychildren.org/English/ages-stages/baby/bathing-skin-care/Pages/Cradle-Cap.aspx
Krinsky, D.L. (2020). Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th Edition. doi:10.21019/9781582123172.