What it is
What is prescribed, and in what form — shampoo, foam, oil, gel or tablet — is chosen around hair texture, washing frequency and how long the head stays covered, because a regimen that ignores those is simply not followed. Some of these conditions scar the follicle if they run untreated, which is why they are named early rather than managed as cosmetic thinning.
What this page covers
- Seborrhoeic dermatitis of the scalp and dandruff
- Scalp psoriasis, with the vehicle chosen for hair texture
- Tinea capitis (fungal scalp infection), including in children, with household screening
- Head lice
- Bacterial folliculitis, boils and abscesses of the scalp
- Acne keloidalis nuchae at the nape
- Folliculitis decalvans
- Dissecting cellulitis of the scalp
- Lichen planopilaris and frontal fibrosing alopecia
- Central centrifugal cicatricial alopecia (CCCA)
- Scalp biopsy for suspected scarring alopecia
- Scalp hyperhidrosis (excessive sweating of the scalp)
- Pilar (trichilemmal) cyst of the scalp
Who it suits
- Someone whose scalp itches or flakes, or keeps producing painful spots, boils or soft connected swellings under the skin, and who wants the scalp skin itself examined rather than another shampoo added to the shelf. Recurring boils in the armpit or groin are asked about at the same visit, because some of these conditions travel with hidradenitis suppurativa
- A parent whose child has a scaly or itchy patch with broken hairs: this is exactly where the diagnosis is settled before anything is applied, where a sample is taken before treatment starts because the course is long, and where the rest of the household, and any pet, is checked alongside
- Someone whose part has widened, whose crown has thinned, or whose frontal hairline has receded, with burning, itch, or scale wrapped around the hairs. The value of the visit here is in naming the condition early rather than in a cosmetic result, and the earlier it is named the more scalp there is left to hold on to
- Someone who covers their head, or whose hair is coarse and tightly curled or chemically relaxed, and for whom a regimen assuming daily washing does not fit. The plan is built around what can actually be sustained, not around what is easy to write on a page
- Not you if what you want is a stronger cortisone to keep using at home without your scalp being examined. The conditions on this page look alike to the eye — fungal infection, psoriasis, seborrheic dermatitis, bacterial folliculitis, an early scarring alopecia — and cortisone over the wrong one makes it worse and blurs it for whoever looks next
When we advise delaying or not treating
- A request to bring hair back from an area where the skin has already scarred. We decline it, and explain why at the start rather than putting it off: once the skin scars the follicle has gone, and no injection, laser, platelet treatment or supplement grows hair from it again. What treatment can do is stop the inflammation so the area does not widen further — an aim that is worked toward, not a promise. That is said at the first visit, not months into treatment
- Potent cortisone on a scalp that has not been diagnosed, particularly where the patch is scaly, crusted, or spongy and tender, and particularly in a child. Cortisone over a fungal scalp infection spreads it and takes away the shape the diagnosis depends on, which makes the diagnosis harder and the treatment longer; over a bacterial infection it settles the appearance and leaves the cause. The sample comes first, then what suits it is prescribed
- Medicated shampoo alone as the treatment for a fungal scalp infection. We decline that: here the fungus lives inside the hair shaft itself, and a topical does not reach the follicle. The condition needs treatment taken by mouth, with the shampoo used alongside it rather than instead of it
- A long antifungal or antibiotic course before a sample is taken, and in recurring folliculitis before a culture and a nasal swab. Repeating an antibiotic without a culture builds resistance and delays control
- Laser, peeling, needling, platelet treatment, mesotherapy or micropigmentation over a scalp that is actively inflamed or infected. It waits until that has settled, and sometimes the answer stays no
- Hairline laser hair removal, forehead reduction and hairline shaping, or a hair transplant — over any receding hairline before a scarring alopecia has been excluded by examination and trichoscopy, whether or not the follicular openings still look intact to you. In frontal fibrosing alopecia specifically, these procedures speed up the very loss you came about
- A scalp biopsy or a cyst removal before we have asked about blood thinners and supplements that affect platelets — the scalp bleeds briskly. Diabetes control and any immunosuppression are reviewed beforehand too, because both slow healing at the biopsy site
- Repeating lice treatment because nits are still stuck to the hair. An empty nit is not evidence of an active infestation and does not call for another dose, and home remedies that are flammable or irritant near the eyes are not used. Head lice has nothing to do with cleanliness and is not treated as something to be ashamed of
Possible effects
Stated in full, because the decision is not sound without them:
- Topical corticosteroid on the scalp, used long and unsupervised: thinning skin and visible vessels, and where it runs onto the face it can set off a rash around the mouth. That is why it is prescribed on a defined ladder and reviewed, rather than as a bottle that keeps being refilled
- Corticosteroid over an infection nobody has diagnosed: it eases the itch whatever lies underneath, so it spreads the fungus and rubs out the defined edge the diagnosis depends on — this is steroid-modified tinea. When it is stopped, a temporary flare is expected, and you are told that before it happens so you do not read it as the treatment failing and go back to the cream
- Corticosteroid injected into the scalp: a dip in the skin at the injected point, a pale mark, and fine thread veins — all three more visible and slower to fade on deeper skin. The steroid is diluted, the sessions are spaced, and a point that has already shown any of them is not injected again
- A scalp biopsy leaves a small round mark, and in Fitzpatrick types IV to VI it carries a risk of a raised or keloid scar at that site. That is why the site is chosen carefully within the hair and why the trade-off is discussed before the procedure rather than after it. It is taken where the answer changes the plan — a suspected scarring alopecia, an unexplained eruption, a lump not behaving like a cyst — and it sometimes has to be repeated if the sample is not diagnostic
- Bleeding: the scalp bleeds more than most sites, so a biopsy or a cyst removal here bleeds more than the same procedure elsewhere. As little hair as possible is shaved, and hair grows back around the site except where a scar has formed
- Long courses taken by mouth, antifungal or antibiotic: they need the follow-up and the blood tests the prescriber decides on, and they interact with other medicines — so every doctor and pharmacist who prescribes for you has to be told what you are taking. Repeating an antibiotic without a culture builds resistance, and that is a medical reason rather than a procedural one
- Lice treatments sting and irritate the scalp, most of all near the eyes; and the treatment is repeated on the schedule you are given rather than every time a nit is spotted
- After the inflammation settles, a pale or dark patch stays on the scalp or at the hairline and takes months to even out. It is the footprint of the inflammation, not a scar, and lasering it now adds risk and corrects nothing
The largest practical risk here is on none of those lines: it is time. Months spent on a shampoo while a scarring alopecia quietly widens, or a severely inflamed fungal infection managed as an ordinary boil until the skin under it has scarred. That is why this begins with the examination and the sample rather than with the prescription.
A note on darker skin
Fitzpatrick types III to VI are most of who is examined here, and scalp disease reads differently on them than in the textbook picture. Redness around the follicle is barely visible on deeper skin, so the diagnosis rests instead on scale, on the follicular openings, on pustules, and on differences in hair caliber, and the scalp is read under magnification rather than by eye — which is why central centrifugal cicatricial alopecia is repeatedly managed for years as ordinary thinning. It is common in coarse, tightly curled hair, so chemical relaxing, heat, braiding and tension are asked about directly rather than skirted. Acne keloidalis nuchae at the nape is common in men with coarse, tightly curled hair in these types, and close clipper work, tight collars and pressing headwear keep it active — discussing that is part of the treatment, not advice added onto it. What needs caution here is specific. Daily medicated shampooing is not realistic in coarse, tightly curled hair, so the regimen is built around what will be kept to. Corticosteroid injections leave a dip, a pale mark and fine thread veins, and on this skin all three are more visible and slower to fade. A scalp biopsy leaves a small mark and carries a risk of a raised or keloid scar in types IV to VI, so its site is chosen within the hair and discussed beforehand. And long-pulsed Nd:YAG hair reduction, where it forms part of the treatment for acne keloidalis nuchae, needs cooling, a test patch and conservative energy, and is not performed over an inflamed or infected lesion. Skin tone is not a reason to avoid any of this; it is the reason for setting it carefully.
Afterwards
- Use what you were given for the period you were given, on the scalp itself rather than on the hair. Medicated shampoo has a contact time before rinsing, and you are shown what it is — without it the use is only nominal
- Do not stop your scalp steroid or extend it on your own; you are shown how it steps down and when it is reviewed. Bring every container to the review, including any mixed cream, oil or product bought without a prescription
- If the diagnosis was a fungal infection: finish the oral course to the end even if the scalp looks better long before it finishes, and keep the review appointment. The comb, the pillow, the cap and the head covering stay with one person until you are told otherwise, the household and any pet are checked, and the school is told according to its own rules
- After a biopsy or a cyst removal: look after the site as you were shown, and expect the small mark. Report bleeding that soaks through a dressing, pain that grows instead of settling, spreading redness, warmth or any discharge. And come back for the result even if the site has healed — the result is the reason the sample was taken
- Report: a patch that is spreading, a swelling that is enlarging, a sore that will not heal, new pustules, a dip or a pale mark at an injection point, hair starting to come away in a new area, or recurring boils in the armpit or groin
- Photograph the part or the patch on your phone in the same light and at the same angle before each review. The scalp changes slowly, and memory alone is what makes people abandon a treatment that is working
- Come back while it is quiet too, not only when it is bad. Most of what is won in these conditions is won at the quiet visits
Honestly
In the scarring conditions the aim of treatment is to stop the inflammation, not to restore hair from areas that have already scarred — hair lost there does not come back, and that is said at the first visit rather than later. Steroid used freely on the scalp thins the skin, so it is prescribed on a defined ladder and reviewed; a sample is taken before starting long antifungal or antibiotic courses; and no laser, peel or needling is performed over a scalp that is actively infected or inflamed.
Common questions
My daughter has a scaly patch and she keeps scratching it. The pharmacy gave me an antifungal shampoo — is that enough?
It is not, and I am sorry to add to your week. On the scalp the fungus lives inside the hair shaft itself, and shampoo does not reach the follicle. The treatment is taken by mouth, with the shampoo used alongside it to reduce what she passes on, not instead of it. A sample is taken before starting, because the course is long. The rest of the household and any pet are checked, and her comb, her pillow and her head covering stay with her alone.
A soft, painful swelling has come up on my son's head and it is getting bigger. Is it a boil?
Have him seen today, not tomorrow. A spongy, tender swelling on the scalp with pus and hair that comes away easily is often a severely inflamed fungal infection called a kerion, and it is treated by mouth. Managed as an ordinary boil and left late, it leaves scarring in which the hair does not come back. This is one of the few things here where the day matters.
I have been using a cortisone solution on my scalp for months, and it comes back every time I stop. Should I keep going with it?
Come in and let us look first. Cortisone eases the itch whatever is underneath it, so it can be sitting on a fungal or bacterial infection, hiding it and letting it widen, and long use on the scalp thins the skin. Do not stop it abruptly on your own either — you are shown how it steps down. Bring the container with you, and any mixed cream or oil you use; the container shortens the visit more than any description does.
Will the hair grow back in the bare area?
The answer turns on one thing the examination decides: whether the skin has scarred. Where the follicular openings are still there and the cause was scale, itch or inflammation, the hair usually returns once the inflammation is controlled. Where the area has gone smooth and shiny and the openings have gone, the hair lost there does not come back, and the aim of treatment becomes stopping it from widening. We say that at the first visit, because hearing it late is heavier.
Does the biopsy leave a mark?
Yes, a small round one. On deeper skin in particular the site can heal as a raised or keloid scar, which is why it is chosen carefully within the hair and why you are told this beforehand rather than afterward. It is taken where the answer changes the plan — not to confirm something already obvious — because years of treating a scarring alopecia without a diagnosis costs far more than a small mark.
Are head lice a sign of poor hygiene? And why are the nits still there after treatment?
They are not, and they have nothing to do with cleanliness; the cleanest homes get them. An empty nit stays glued to the hair after what was inside it has hatched, and its presence is not evidence of an active infestation or a reason for another dose — an active infestation is confirmed by seeing a live louse with a fine comb. The treatment is repeated on the schedule you were given, not every time you spot a nit. And keep away from home remedies that are flammable or irritant near the eyes.