Atopic dermatitis of the scalp
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Atopic dermatitis of the scalp is a form of atopic dermatitis (AD) affecting the hairy skin of the scalp. AD is a chronic, relapsing inflammatory skin disease of immunologic origin, associated with epidermal barrier dysfunction and an excessive immune response to environmental factors. On the scalp the disease presents primarily with itching, dryness, redness and scaling of the epidermis. Lesions may be periodic or chronic and often coexist with other atopic manifestations, such as bronchial asthma or allergic rhinitis. Because of the similarity of symptoms, atopic dermatitis of the scalp is often mistaken for dandruff or seborrheic dermatitis.
Atopic dermatitis of the scalp – causes
The pathogenesis of atopic dermatitis is complex and results from the overlap of genetic, immunological, and environmental factors. A key role is played by impairment of the epidermal barrier function, which leads to increased water loss through the skin (so-called TEWL – transepidermal water loss) and easier penetration of allergens and irritants.
The most important causes and risk factors for the development of atopic dermatitis of the scalp include:
- genetic predispositions, especially mutations in the filaggrin gene (FLG), a protein responsible for the proper structure of the epidermis
- immune abnormalities, particularly excessive activation of Th2-type T lymphocytes
- atopy in the family history, including atopic dermatitis, asthma, or allergic rhinitis
- environmental factors, such as air pollution, tobacco smoke, or low humidity
- contact or airborne allergens, e.g., house dust mites, animal dander, or plant pollen
- irritants, including harsh detergents, some hair cosmetics, or frequent washing of the scalp
In many patients, disease symptoms also worsen under the influence of psychological stress, hormonal changes, and skin infections. Disruption of the skin microbiome also plays an important role – particularly excessive colonization by Staphylococcus aureus bacteria, which can intensify the inflammatory response.
Atopic dermatitis of the scalp – what does it look like
The symptoms of atopic dermatitis of the scalp result mainly from chronic inflammation and disturbances in epidermal barrier function. The clinical picture may vary depending on the patient's age, disease severity, and the presence of exacerbating factors.
The most common symptoms include:
- intense itching of the scalp, often worse at night
- dry skin (xerosis) and a feeling of tightness
- erythema, i.e., redness of the skin
- scaling of the epidermis, which may resemble dandruff
- small inflammatory papules or excoriations resulting from scratching
- skin thickening (lichenification) in the course of chronic inflammation
As a result of intense itching, patients often scratch the skin, which can lead to:
- secondary bacterial or fungal infections,
- the formation of crusts and erosions,
- weakening or thinning of hair at sites of pronounced inflammation.
Atopic changes on the scalp may involve the entire hairy scalp or appear in specific areas, most often:
- in the occipital area,
- behind the ears,
- at the border of the hairy scalp and the forehead.
Because of the similarity of symptoms, the differential diagnosis should include, among others:
- seborrheic dermatitis,
- scalp psoriasis,
- contact dermatitis,
- fungal infection of the scalp.
Atopic dermatitis of the scalp – how to treat
Treatment of atopic dermatitis of the scalp is symptomatic and long-term, because the disease follows a chronic and relapsing course. Therapy focuses on restoring the proper function of the epidermal barrier, reducing inflammation and limiting itch.
The basis of management is systematic scalp care:
- use of mild dermatological shampoos, without strong detergents (e.g. SLS, SLES)
- regular use of emollient preparations that rebuild the skin's lipid barrier
- avoiding irritant factors, such as aggressive hair styling cosmetics
Pharmacological treatment includes:
- topical glucocorticosteroids of appropriate potency
- calcineurin inhibitors (e.g. tacrolimus, pimecrolimus)
- antipruritic and anti-inflammatory preparations
- in case of superinfection – antibiotics or antifungal agents
In patients with severe disease, systemic treatment may be necessary, including:
- immunomodulatory drugs,
- dermatological phototherapy,
- biologic therapies (e.g. monoclonal antibodies that inhibit interleukins responsible for the inflammatory response).
For chronic skin lesions, dermatological procedures that support skin regeneration may also be helpful, such as laser therapies, skin regenerative procedures or procedures that improve the function of the epidermal barrier. Although they are not the basis of AZS treatment, they can support skin repair processes and improve patient comfort.
Long-term disease control, identification of exacerbating factors and systematic skin care, which reduce the risk of relapses and improve patients' quality of life, are of key importance in therapy.
Atopic dermatitis of the scalp – scalp care for AD
Proper care of the scalp is one of the most important elements of controlling atopic dermatitis. In AZS there is damage to the epidermal barrier, increased water loss and greater susceptibility of the skin to irritants and allergens. For this reason daily care should focus on the restoration of the hydrolipidic barrier, reduction of skin dryness and limitation of inflammation and itching.
The basis of care is the use of mild cleansing products intended for atopic skin. Shampoos used in AZS should have a physiological pH and as simple a composition as possible. It is recommended to avoid strong detergents such as SLS (sodium lauryl sulfate) and SLES (sodium laureth sulfate), which can further damage the epidermal barrier and increase irritation. More favorable are cleansing agents based on mild surfactants, e.g. cocamidopropyl betaine or plant-derived glucosides.
An important element of therapeutic care is the use of emollient products. Emollients contain ingredients that:
- replenish epidermal lipids (e.g. ceramides, cholesterol, fatty acids),
- reduce transepidermal water loss,
- decrease the sensation of itching and skin tightness.
For the scalp they may take the form of light lotions, emulsions or special scalp products that do not weigh the hair down and spread easily.
In scalp care for AZS it is also recommended to:
- wash the scalp with lukewarm, not hot water, because high temperature intensifies itching and skin drying,
- gently dry the scalp with a towel, without vigorous rubbing,
- limit the use of styling cosmetics that may contain alcohol, fragrances or other potential allergens,
- avoid frequent hair dyeing or the use of strong chemical treatments.
For some patients it is also beneficial to use products containing substances that soothe inflammation, such as panthenol, allantoin, niacinamide or plant extracts with soothing properties.
In cases of severe itching it is very important to limit scratching of the skin, because it leads to epidermal damage, secondary bacterial infections and worsening of inflammation. Therefore in the treatment of AZS the concurrent use of antipruritic preparations and regular skin moisturization is often recommended.
Systematic and appropriately selected scalp care can significantly reduce the frequency of disease exacerbations, improve patient comfort and support the effect of dermatological treatment. In clinical practice it is regarded as one of the fundamental elements of long-term management of atopic dermatitis.
