Your physician has reviewed your medical information and has prescribed a prescription dandruff shampoo containing ciclopirox, zinc pyrithione, salicylic acid, tea tree oil, and provitamin B5 to treat your dandruff.

Note that this treatment plan is for your general educational and informational purposes only. It is not intended to substitute the personalized medical advice of your physician. It is essential for you to understand the potential risks and benefits of treatment. Always follow your physician’s treatment instructions, and let your physician know if your symptoms persist or if you experience new symptoms or side effects after you begin taking your medication. If you have any questions or concerns about your treatment after reading the information provided here or in the package insert, please contact your Ro-affiliated physician or primary care provider for additional guidance.

Telemedicine has the advantage of convenience, but it relies on your honesty and your involvement in the process. Keep every healthcare provider informed of what you are taking. If any of the following occur, please contact your Ro-affiliated physician:

• Your health status changes or you experience new symptoms

• You experience side effects

• The medicine does not work or stops working over time

• You are prescribed new medications or change how you are taking your existing medications

The medical term for dandruff is seborrheic dermatitis (“seb-o-REE-ic der-ma-TIE-tis”). Seborrheic dermatitis can affect the skin on parts of the body other than the scalp. Dandruff can be asymptomatic (other than flakes), or accompanied by itchiness.

Up to 50% of adults in the US suffer from dandruff, and about 5% (14 million) seek prescription treatment for dandruff. It is slightly more prevalent in men than in women, and people typically start experiencing dandruff around puberty. Dandruff can affect people of any race. The symptoms tend to be worse with stress and during the winter when the weather is cold and dry, and better during the summer.

People living with HIV/AIDS have a slightly higher prevalence of dandruff. In these cases, it also tends to be a more extensive and severe form of seborrheic dermatitis that also involves inflammation and other areas of the body. People with Parkinson’s can also have a severe form of seborrheic dermatitis.

It’s important to know that dandruff isn’t caused by bad hygiene, and it’s not contagious. The presence of scalp flakes often impacts social situations, especially when dandruff shows up on clothing (usually dark clothes), and may cause anxiety.

We don’t really know what causes dandruff. It may have something to do with hormones, specifically androgens (hormones associated with typically male characteristics). There’s also a suspected association with a fungus called Malassezia that is also not fully understood. Although it’s NOT considered a fungal infection (Malassezia is found normally on the skin of many people and is harmless), antifungal medication works for some reason that’s not yet clear.

There’s no cure for dandruff, and treatment is aimed at relieving the symptoms (stop the itching and make the flakes go away). Most dandruff shampoos available over the counter or by prescription contain zinc, selenium, or an antifungal as the active ingredient.

Ro’s custom shampoo includes the following ingredients (including shampoo base):

• Ciclopirox: antifungal agent

• Zinc pyrithione: also has some antifungal activity, as well as antibacterial properties against skin bacteria

• Salicylic acid: removes scaly skin and loosens flakes associated with dandruff

• Tea tree and peppermint oil: tea tree oil has some antifungal activity and provides a “tingling” effect

• Calcium pantothenate (B5): helps hair absorb and retain moisture

Use with caution in areas of skin abrasion, as applying to these areas can worsen irritation. Avoid exposure to the eyes or mouth. See below under “Important Medication Information” for more on warnings.

Wet your hair and apply an amount of shampoo approximately equal to 1 teaspoon to your scalp (or up to 2 teaspoons for longer hair). Massage into the scalp for 3-5 minutes. Afterwards, you can use your regular shampoo as usual (this is optional). Repeat 1-2 times a week for 4 weeks.

Dermatologists sometimes recommend modifications based on individual hair type and typical hair regimen. For example, tightly coiled and chemically treated hair tends to be more fragile and generally requires more moisturizing and less frequent washing at baseline, so if your normal routine is to wash your hair once a week or less, it’s okay to use the dandruff shampoo at that frequency. Dandruff shampoo can also be used intermittently (e.g. once a week) for prevention.

Ketoconazole-based shampoos have similar efficacy to ciclopirox shampoos (and also work through antifungal activity). Some anecdotal evidence suggests they may be more drying to the scalp than ciclopirox, but there are currently no studies comparing the drying effects of ketoconazole and ciclopirox-based shampoos. Topical steroids are also an option and are equally effective, but are associated with more side effects. Other antifungals, including selenium sulfide, have not been shown to be as effective as ketoconazole or ciclopirox. Selenium sulfide-containing shampoos are also often associated with intense burning. There are also other formulations of topicals, such as “leave on” shampoo that is not washed off.

Note that for other forms of seborrheic dermatitis (i.e., not just on the scalp, or more severe seborrheic dermatitis), the treatment options may be different.

The information below is taken from the Prescribers’ Digital Reference (PDR), which can be found here.

Side Effects

The following is a summary of important potential side effects and does not include every side effect possible. Be sure to read the package insert and report any side effects you experience whether on the list below or not.

Severe

• Ventricular tachycardia (irregularly fast heart rate)

Moderate

• Erythema (redness)

• Contact dermatitis (skin inflammation from contact with a substance)

Mild

• Pruritus (itching)

• Nail discoloration Other reactions reported in 1% of individuals or less include alopecia, hair discoloration, rash, xerosis (dry skin), acneiform rash, and headache.

Contraindications

• This shampoo is contraindicated if there is hypersensitivity to any of its components.

Precautions

• Use with caution in areas of skin abrasion, as applying to these areas can worsen irritation.

• Avoid exposure to the eyes or mouth.

• Because studies on the efficacy and safety of ciclopirox excluded people with a history of immunosuppression, ciclopirox is not recommended in these patients, including patients on corticosteroid therapy (oral, topical, or inhaled corticosteroids). Patients who were on medication for seizure disorder were also excluded from these studies.

• Ciclopirox is a category B drug by the FDA (no studies in pregnant women; treatment may be considered if benefits outweigh risks). The amount of topical ciclopirox that may be absorbed into the bloodstream is about 1%.

Drug interactions

There are no drug interactions associated with ciclopirox products.