Forever Flakes: Why Won't My Dandruff Disappear?

Dealing with dandruff that just won't seem to disappear can be an exasperating ordeal. Despite experimenting with various shampoos, oils, and home remedies, many find themselves stuck in a cycle of itching scalps and persistent flakes, wondering, “Why is my dandruff not going away?” 

The answer to this seemingly simple question entails a complex web of factors contributing to scalp health. From environmental influences to lifestyle choices and underlying medical conditions, the causes of stubborn dandruff can be many.

Dandruff is a common scalp condition medically termed pityriasis simplex. It manifests as scaling desquamation of the scalp, essentially the shedding of excess scalp corneocytes (keratinised cells) in visible flakes.

Dr Meghna Maur, a dermatologist, trichologist and cosmetologist, explains, “In easier terms, dandruff is like your scalp shedding too much skin. Normally, this shedding happens, but the flakes are so small you wouldn't notice them. With dandruff, the skin cells build up and flake off in bigger chunks, like white snowflakes landing on your hair.”

Dandruff is commonly perceived as a single condition, yet it can appear in several forms, each influenced by different underlying causes.

1. Dry scalp dandruff: This is the most common type. It's characterised by small, white flakes that shed from the scalp. Dr Meghna says, “Dry scalp dandruff can result from dry weather conditions, the use of harsh shampoos, and a lack of humidity.”
2. Seborrheic dermatitis: This condition, which is a more severe type of dandruff, leads to itchy, red patches and flaking on the scalp. It's often linked to overproduction of oil by the scalp glands and can also affect areas like the eyebrows, beard, ears, and chest.
3. Oily scalp dandruff: This type is caused by excess oil production on the scalp, similar to seborrheic dermatitis, but without intense redness and inflammation. The flakes tend to be larger, yellowish, and oilier than those of dry scalp dandruff.
4. Dandruff caused by skin conditions: Certain skin conditions like eczema and psoriasis can manifest on the scalp, causing flaking that resembles dandruff. These conditions often require different treatment approaches than typical dandruff.

Dandruff can affect anybody, regardless of age. One important thing to know about dandruff is that it can appear during puberty due to hormonal changes and persist through adulthood. It's also not uncommon in babies.

• Hormonal fluctuations: Androgens, hormones that increase during puberty and young adulthood, can stimulate oil production in the scalp. This creates an ideal environment for Malassezia yeast, potentially leading to dandruff.
• Genetics: Just like hair or eye colour, some people are more prone to having an oily scalp due to their genes. Additionally, some may have a genetic predisposition to a more robust immune response to Malassezia, making them more susceptible to dandruff. 
• Medical conditions: Certain neurological conditions like Parkinson's disease and weakened immune systems due to HIV/AIDS can also increase dandruff risk.

This culprit isn't a harmful organism; it's a type of yeast that naturally lives on most scalps and feeds on scalp oils. However, in some individuals, the immune system overreacts to Malassezia, causing an inflammatory response. This speeds up skin cell turnover, leading to the rapid shedding of scalp cells that form the characteristic white flakes of dandruff. 

While less common than Malassezia-related dandruff, dry skin can also cause scalp flaking. This type of dandruff typically consists of smaller, finer flakes than the larger, oilier flakes associated with Malassezia. Factors like cold, dry weather or harsh shampoos can contribute to dry scalp and dandruff.

Dr Meghna says, “It is easy to detect dandruff. It may be dandruff when you see visible flakes, an itchy scalp, or scaly patches on the scalp.” She suggests consulting a doctor before using any remedies that may worsen the condition.

Dr Meghna says, “Malassezia grows and causes fungus, and if people share combs, hats, pillowcases, towels, etc., there is a chance of passing the fungus on to another user. Dandruff itself isn't contagious, but the fungus that causes dandruff is contagious. I often advise people with dandruff not to share their combs with others.”

Yes, dandruff can cause acne. Dr Meghna says, “Flaky scalp skin (dandruff) can fall onto your forehead and clog pores, while excess scalp oil can migrate down your face, further plugging those pores. Dandruff-related inflammation may even irritate your facial skin and worsen existing acne. Dandruff's inflammatory nature might further irritate facial skin and exacerbate acne. While not the sole cause, dandruff can contribute, especially to forehead acne. The fungus causing dandruff can also lead to folliculitis, which can occur on the face, upper back and shoulders.”

Dr Meghna explains that washing frequency depends on your hair type—oily scalps with dandruff benefit most from frequent washing with a dandruff shampoo. She says, “Dry scalps with dandruff need a gentler approach: wash every 3-4 days with a hydrating shampoo and use dandruff shampoo 2-3 times a week.” No matter your hair type, if dandruff persists, see a dermatologist for a personalised plan.

Dr Meghna explains that anti-dandruff shampoos pack a punch against those pesky flakes! Ingredients like ketoconazole and zinc pyrithione target the root cause (often yeast), while salicylic acid buffs away dead skin cells. Studies show they can be even more effective than other techniques at controlling dandruff.

Dr Meghna states a few reasons why your dandruff might be persistent:

• Incorrect treatment: Not all dandruff is created equal! She says, “You might be using an anti-dandruff shampoo that doesn't target the root cause of your dandruff. For instance, if your dandruff is due to dry skin, a shampoo formulated for Malassezia yeast overgrowth won't be very effective.”
• Improper technique: Not following the shampoo's instructions can limit its effectiveness. “Ensure the shampoo remains on your scalp for the recommended time to let the active ingredients do their job,” she says.
• Frequency issues: Using an anti-dandruff shampoo too infrequently or too often can hinder results. Find the right balance based on the shampoo's strength and your dandruff severity. Even after the dandruff has largely disappeared, continue to use anti-dandruff shampoo at least once a week for a clean and healthy scalp.

Dandruff usually doesn't directly cause hair loss, but there can be a connection. Hair goes through a natural growth, resting, and shedding cycle. Dandruff flakes are simply dead skin cells shedding from your scalp at a faster rate than usual. This shedding doesn't disrupt the hair growth cycle itself. But there are a few external reasons for hair loss when you have dandruff. 

• Over-scratching: Dandruff can be itchy, and the urge to scratch can be strong. However, aggressive scratching can damage hair follicles, leading to temporary hair loss and irritation. Chronic dandruff may lead to long-term scalp inflammation, which can further contribute to hair loss.
• Underlying conditions: Sometimes, dandruff can be a symptom of an underlying scalp condition that causes hair loss. “Hair loss can result from seborrheic dermatitis — a more severe type of dandruff — and scalp psoriasis,” says Dr Meghna.

If you’re experiencing significant hair loss alongside dandruff, or if your dandruff is severe and unresponsive to over-the-counter dandruff shampoos, it’s best to consult a doctor or dermatologist.

Dr Meghna suggests “using shampoos with ingredients like salicylic acid that exfoliates dead skin cells, coal tar, that reduces itching and inflammation, and ketoconazole, an antifungal can be very effective for managing dandruff. But do make sure to verify these with your doctor.” 

Each scalp is unique, and what works for one person may not be the ideal solution for another. By understanding the root causes of your dandruff and implementing specific actions for its treatment and prevention, you can bid farewell to those pesky flakes and embrace a healthier, happier scalp.