“Men's scalp conditions are often mistreated.” Dr. Doina Ioniță, MedLife: the confusions that spoil the treatment

The most common scalp conditions in men are also often confused. Many men notice dandruff, redness, unsightly scales on the scalp, itching and choose to use heavily promoted products or even seek the advice of the pharmacist, without having a clear picture of the cause. “In most cases, these common symptoms in men are caused by scalp psoriasis or seborrheic dermatitis,” he explains. Dr. Doina Ionițădermatologist within MedLife Solomed hyperclinics from Pitesti. Treatment mistakes perpetuate scalp problems, and over time, the consequences can be even more serious: hair can become brittle and thin.

“Changes in the scalp are in the top 5 most common reasons why men go to the dermatologist”, says Dr. Ioniță. The symptoms seem like “dandruff”, but they can indicate a chronic inflammation that returns to the scalp, worsens in the winter and, if not treated correctly, can lead to hair thinning over time.

“Dandruff” that won't go away: two diagnoses that are often confused

In the office, Dr. Doina Ioniță very often sees patients who have tried several products on their own, some of them gave results for a while, then the effect disappeared. Meanwhile, the discomfort continues, and the problem returns periodically, especially in the cold season.

From a dermatological point of view, the two most common causes of “persistent dandruff” in men are seborrheic dermatitis and scalp psoriasis. At the beginning, they can look almost identical: “Both psoriasis of the scalp and seborrheic dermatitis manifest themselves in approximately the same way. Redness, scales and itching on the scalp,” says the doctor.

Errors arise precisely from this confusion: the wrong treatment of either of these two chronic conditions can lead to only temporary relief or even worsen dryness, inflammation and irritation. “First of all, it is important to make the correct diagnosis. Psoriasis and seborrheic dermatitis are conditions that are similar, but have different causes and different treatment”, emphasizes Dr. Ioniță.

Differences that help dermatologists

The differences between the two scalp conditions are in the details, and they can be seen on clinical examination. In psoriasis of the scalp, the scales are usually “whitish, dry, easily removable, arranged in a thick layer”. In seborrheic dermatitis, the scales are “yellowish, greasy, adhering to the hair”.

Another sign that can guide the doctor is that seborrheic dermatitis can also affect the face, not just the scalp. “Patients who have seborrheic dermatitis often experience flakes between the eyebrows and on the nose,” explains the doctor. Psoriasis, on the other hand, has classic “key areas”: elbows, knees, sacral area and scalp, but it can manifest exclusively on the scalp (most often, in the occipital area, towards the back of the head).

However, there are also cases that complicate the situation: a patient may have lesions only on the scalp, and the signs may be mixed. In dermatology there is even a term for this overlap: sebo-psoriasis. “The patient fulfills clinical criteria for both seborrheic dermatitis and psoriasis, having lesions only on the scalp. And it is difficult to differentiate clinically”, says Dr. Ioniță.

Why both problems get worse in winter

Many men notice that scalp problems increase after the summer season and become more troublesome in the fall and winter. Dr. Ioniță confirms: “Psoriasis and seborrheic dermatitis improve in the warm season and worsen in the cold season.”

It is one of the few situations in which the sun can bring about an improvement in the clinical aspect – without meaning that excessive exposure is a “therapy”. “They are among the few ailments that show an improvement in the sun… This does not mean that we must expose ourselves to the sun without protection”, draws the doctor's attention.

Psoriasis: an immune inflammatory disease

Psoriasis is a chronic condition with an inflammatory mechanism, in which the immune response is deregulated. Dr. Ioniță wants to correct a common confusion: psoriasis is not, strictly speaking, an autoimmune disease. “For autoimmune diseases, we have autoantibodies against our own structures, while psoriasis is an exaggerated inflammatory response. More clearly, it is an immune disease, in which the inflammatory response is exaggerated”, explains the specialist.

The causes are multifactorial: genetic predisposition, lifestyle factors and certain triggers. The doctor lists obesity, smoking, alcohol consumption, some infections and stress. “Many people say they developed psoriasis after a major stressful event,” says Dr. Ioniță.

Seborrheic dermatitis: Sebum, genetic predisposition and a “normal” fungus that overgrows

In seborrheic dermatitis, the mechanism is different. The condition is more common in people who, genetically, have a sebum composition that favors the overgrowth of the Malassezia fungus – a microorganism normally present on everyone's skin. “In people with seborrheic dermatitis, this fungus finds more food, and through the degradation of the components of the sebum, compounds are produced that trigger inflammation in the scalp,” explains Dr. Ioniță.

This also means that the objective of the treatment is not “the definitive elimination of the fungus”, but to keep its multiplication under control.

Mistake 1: treatment in the absence of a clear diagnosis

The correct first step, in both conditions, is the dermatological diagnosis, precisely because the symptoms are similar. Without it, many patients apply treatments that are not appropriate or use them in a way that leads to rapid relapses. Dr. Ioniță emphasizes the importance of consultation and clinical examination, which determine the direction, and in severe forms of psoriasis, a biopsy may be necessary for confirmation and to choose the right treatment.

Mistake 2: different shampoos, same active substance

One of the important rules in seborrheic dermatitis is to alternate shampoos when one of them starts to lose its effectiveness. The most common situation that the doctor sees in cases of seborrheic dermatitis is when the patient changes products, but does not, in fact, change the active substance. “I have patients who come with three different shampoos, which I use in rotation, but they all have the same active ingredient. The only change was the name of the shampoo, but the substance itself remained the same,” explains Dr. Ioniță.

In seborrheic dermatitis, treatment is often based on antifungals. A well-known example is ketoconazole (from the “-azole” class, easily recognizable by the ending). But the doctor says that over time, if the same substance is used over and over again, the effectiveness can decrease, as the fungus gets used to it. That's why they recommend rotating them: “A patient with seborrheic dermatitis should have two or three shampoos at home that they can use alternately.”

In addition to “-azoles”, Dr. Ioniță mentions other substances used in practice: selenium sulfide, zinc pyrithionate, ciclopirox. The solution is to rotate between different substances, not just between brands.

Mistake 3: Treating with antifungals that dry out the scalp and skipping moisturizing

The third mistake is the one that, paradoxically, can perpetuate the vicious circle: we treat the fungus, but we aggravate the dryness, and the dryness accentuates the inflammation. “These anti-fungal shampoos are drying, and dryness, over time, worsens seborrheic dermatitis,” says Dr. Ioniță.

Therefore, the correct scheme includes two components: controlling the fungus and moisturizing the scalp. “In seborrheic dermatitis, a wash should contain an anti-fungal shampoo and a shampoo to soothe and moisturize the scalp,” explains the doctor. In the case, the recommendation is every wash; after the pus passes, the antifungal shampoos remain once-twice a week, and the moisturizing ones continue constantly.

How to treat psoriasis correctly

In psoriasis, the major problem is the unrealistic expectation of a definitive cure. “Psoriasis is a chronic disease, the treatment only keeps the condition under control and the results are observed strictly during its duration”, says Dr. Ioniță. Therefore, the role of the dermatologist is to teach the patient how to manage the pimples and how to maintain the results.

The treatment usually starts with local solutions: for hydration, removal of crusts and control of inflammation. If the answer is insufficient, you can also turn to phototherapy – treatment with the help of special medical lamps – but access to such services is difficult in certain areas of the country, including Argeș county. For moderate-severe forms, systemic treatment can be reached, but this is indicated in the context of an extensive disease and after evaluations.

Between sessions, the routine changes: moisturizing and applying anti-inflammatory substances once or twice a week to maintain control.

When “dandruff” is combined with hair loss: inflammation can thin the hair

For many men, the real motivation to treat properly begins when the fear of hair loss arises. Dr. Ioniță says that men are generally compliant “because they care a lot about their hair”. And he adds a caveat: Persistent, untreated inflammation can lead to hair thinning over time. “This persistent, untreated inflammation over time also leads to hair thinning.”

In the case of men with hair transplantation, the management must be done carefully, in stages: in the pus, the inflammation is treated as a priority, and after the control of the pus, it is returned to scalp care and hydration, to prevent relapses.

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