Dandruff and seborrhoeic dermatitis exist on a spectrum, driven by Malassezia yeast colonisation, host inflammatory response, and microbiome dysbiosis. The condition affects approximately 50% of the adult population at some point; in Indian humid climates it tends to be chronic-relapsing rather than self-limiting.
Standard anti-Malassezia + anti-inflammatory protocol (combinations of):
- Ketoconazole 2% shampoo, azole antifungal; inhibits ergosterol synthesis disrupting Malassezia cell membrane; first-line workhorse.
- Selenium sulphide 2.5% shampoo, anti-Malassezia + anti-proliferative; effective alternative.
- Zinc pyrithione 1-2% shampoo, first-line OTC option; anti-Malassezia + anti-inflammatory.
- Ciclopirox olamine 1% shampoo or 1.5% lotion, broad-spectrum antifungal + anti-inflammatory + antibacterial; particularly useful in ketoconazole-resistant cases.
- Coal tar shampoo, anti-proliferative + anti-inflammatory; effective for plaque-pattern SD.
- Salicylic acid 2-3% shampoo, keratolytic; removes accumulated scale.
For inflammatory flares: short-course topical corticosteroid (low-mid potency: hydrocortisone 1%, mometasone 0.1%), typically 5-7 days, never long-term continuous.
Emerging refractory-disease therapies: PDE4 inhibitors (roflumilast 0.3% foam, crisaborole, apremilast), topical JAK inhibitors, probiotics + microbiome-targeted therapies (early-stage; not yet first-line).
Standard combination protocol: ketoconazole 2% shampoo + zinc pyrithione 1% shampoo on alternating days (Cochrane RCT data supports the combination over monotherapy), with topical steroid short course for inflammatory flares + oil-free non-comedogenic moisturiser for surrounding scalp/face areas.
