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Liquorice 7% versus selenium sulfide 1% shampoos in the treatment of dandruff: A clinical trial

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Rahmatollah Salmanpoor
Rahmatollah Salmanpoor
Rahmatollah Salmanpoor
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Nasrin Saki at Shiraz University of Medical Sciences
Nasrin Saki
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Iranian Journal of Dermatology © 2012 Iranian Society of Dermatology
Liquorice 7% versus selenium sulfide 1% shampoos in the
treatment of dandruff: a clinical trial
Dear Editor,
Dandruff is a common inflammatory condition
affecting more than half of the population. Many
products are used to treat dandruff. Selenium-
sulfide as an anti-malassezia, keratolytic and
cytostatic agent and liquorice, extracted from
glycyrrhiza glabra, with anti-yeast activities are
known to be antidandruff 1-3. We conducted a
placebo controlled-randomized clinical trial to
compare antidandruff activity of liquorice 7%
shampoo, selenium-sulfide 1% shampoo and a
placebo. Study participants were randomly selected
from patients who referred to our dermatology
clinic and those diagnosed with dandruff in our
screening program held in 10 Shiraz high schools.
The study was approved by the committee of
medical ethics. Active study groups included
patients who used liquorice 7% shampoo in one
group and those who used selenium-sulfide 1%
shampoo in the other group. After discontinuing
any other topical preparation or shampoo for two
weeks prior and during the study, patients were
asked to wash their hair twice weekly with the
given shampoo. Data regarding the severity of
dandruff, scalp inflammation, pruritus, hair loss
and also eye irritation before and after treatment
were obtained with a questionnaire. The severity
of dandruff was evaluated with Kligman method 4.
Scalp inflammation and pruritus were described as
mild, moderate and severe clinically and through
asking the patients, respectively. Hair loss was
graded as mild (100-150/day), moderate (150-200/
day), and severe (more than 200/day) before and
after therapy. Pityrosporum.ovale density was
calculated by a microbiologist, using the mean
yeast count in 4 microscopic fields of methylene
blue-stained smear obtained from the most dandruff
affected scalp areas.
A total of 72 patients (60 male, 12 female) with
a mean age of 19 (14-70 years) for the liquorice
7% shampoo, a total of 68 patients (68 male, 4
female) with a mean age of 17 (14-65 years) for
the selenium-sulfide 1% shampoo and a total of
63 patients (63 male, 0 female) with a mean age of
16 (14-32 years) for the placebo group completed
the study.
Dandruff Severity Score (DSS) decreased from
2.6 to 2.2 after 4 weeks (15% decrease) in the
liquorice 7% shampoo group and a 37% decrease
was achieved (from 2.7 to 1.7) in the selenium-
sulfide 1% group. DSS decreased by 19% (from 2.6
to 2.1) in the placebo group (P-value <0.05). The
three shampoos significantly decreased dandruff
severity with the best result for selenium-sulfide
1%. Scalp inflammation declined in 5.7%, 15.4% and
19.4% of patients who used liquorice 7%, selenium-
sulfide 1% and placebo shampoo, respectively.
None of the shampoos could significantly decrease
scalp inflammation (P-value > 0.05). Pruritus
decreased in 37.5% and 60% of the participants
who used liquorice and selenium-sulfide shampoo,
respectively. About 25% of the patients who used
placebo reported decreased pruritus. So, both
liquorice and selenium-sulfide but not the placebo
significantly decreased pruritus. Moreover, 33.8%,
18.2%, and 16.7% of patients who used liquorice,
selenium-sulfide and placebo shampoo reported
decreased hair loss showing that only liquorice
shampoo might decrease hair loss. Liquorice
shampoo, comparing to the other two, caused the
most eye irritation (P-value <0.05). Data revealed
no significant decrease in the density of P.ovale
in all the three groups (P-value>0.05).
Our study showed no significant difference
between placebo and liquorice in decreasing
dandruff severity. Regular hair wash can reduce
dandruff. None of them had anti-inflammatory
effects. Liquorice and selenium-sulfide had a
significant antipruritic activity. Liquorice might
decrease hair loss which has not been reported
to date and needs more investigations by future
studies. Liquorice shampoo caused the most eye
irritation. In conclusion, liquorice 7% shampoo
Iran J Dermatol 2012; 15: 144-145
Liquorice versus selenium sulfide shampoos in the treatment of dandruff
145
Iranian Journal of Dermatology, Vol 15, No 4, Winter 2012
cannot be used as a suitable anti-dandruff shampoo.
On the other hand, further in-depth investigations
are required regarding its anti-hair loss and
antipruritic activity.
Rahmatollah Salmanpoor, MD1
Nasrin Saki, MD1
Gholamreza Mahmoodi, MD 2
1. Dermatology Department and Shiraz Skin Research
Center, Shiraz University of Medical Sciences, Shiraz,
Iran
2. Dermatology Department, Yasooj University of Medical
Sciences, Yasooj, Iran
Corresponding Author:
Nasrin Saki, MD
Dermatology department, Faghihi hospital, Zand street,
Shiraz, Iran
Email: nasrinsa85@yahoo.com
Conflict of interest: None to declare
Received: 20 July 2011
Accepted: 27 November 2011
REFEREnCES
1. Ranganathan S, Mukhopadhyay T. Dandruff: the most
commercially exploited skin disease. Indian J Dermatol
2010;55: 130-4.
2. Shai A, Maibach HI, Baran R. Handbook of cosmetic skin
care. 1st edition. London: Martin Dunitz Co; 2001.
3. Waldroup W, Scheinfeld N. Medicated shampoos for the
treatment of seborrheic dermatitis. J Drugs Dermatol
2008;7: 699-703.
4. Kligman AM, McGinley KJ, Leyden JJ. The nature of
dandruff. J Soc Cosmet Chem 1976; 27:111–39.
Topical antifungals for seborrhoeic dermatitis
Article
Full-text available
  • Apr 2015
Background: Seborrhoeic dermatitis is a chronic inflammatory skin condition that is distributed worldwide. It commonly affects the scalp, face and flexures of the body. Treatment options include antifungal drugs, steroids, calcineurin inhibitors, keratolytic agents and phototherapy. Objectives: To assess the effects of antifungal agents for seborrhoeic dermatitis of the face and scalp in adolescents and adults.A secondary objective is to assess whether the same interventions are effective in the management of seborrhoeic dermatitis in patients with HIV/AIDS. Search methods: We searched the following databases up to December 2014: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 11), MEDLINE (from 1946), EMBASE (from 1974) and Latin American Caribbean Health Sciences Literature (LILACS) (from 1982). We also searched trials registries and checked the bibliographies of published studies for further trials. Selection criteria: Randomised controlled trials of topical antifungals used for treatment of seborrhoeic dermatitis in adolescents and adults, with primary outcome measures of complete clearance of symptoms and improved quality of life. Data collection and analysis: Review author pairs independently assessed eligibility for inclusion, extracted study data and assessed risk of bias of included studies. We performed fixed-effect meta-analysis for studies with low statistical heterogeneity and used a random-effects model when heterogeneity was high. Main results: We included 51 studies with 9052 participants. Of these, 45 trials assessed treatment outcomes at five weeks or less after commencement of treatment, and six trials assessed outcomes over a longer time frame. We believe that 24 trials had some form of conflict of interest, such as funding by pharmaceutical companies.Among the included studies were 12 ketoconazole trials (N = 3253), 11 ciclopirox trials (N = 3029), two lithium trials (N = 141), two bifonazole trials (N = 136) and one clotrimazole trial (N = 126) that compared the effectiveness of these treatments versus placebo or vehicle. Nine ketoconazole trials (N = 632) and one miconazole trial (N = 47) compared these treatments versus steroids. Fourteen studies (N = 1541) compared one antifungal versus another or compared different doses or schedules of administration of the same agent versus one another. KetoconazoleTopical ketoconazole 2% treatment showed a 31% lower risk of failed clearance of rashes compared with placebo (risk ratio (RR) 0.69, 95% confidence interval (CI) 0.59 to 0.81, eight studies, low-quality evidence) at four weeks of follow-up, but the effect on side effects was uncertain because evidence was of very low quality (RR 0.97, 95% CI 0.58 to 1.64, six studies); heterogeneity between studies was substantial (I² = 74%). The median proportion of those who did not have clearance in the placebo groups was 69%.Ketoconazole treatment resulted in a remission rate similar to that of steroids (RR 1.17, 95% CI 0.95 to 1.44, six studies, low-quality evidence), but occurrence of side effects was 44% lower in the ketoconazole group than in the steroid group (RR 0.56, 95% CI 0.32 to 0.96, eight studies, moderate-quality evidence).Ketoconozale yielded a similar remission failure rate as ciclopirox (RR 1.09, 95% CI 0.95 to 1.26, three studies, low-quality evidence). Most comparisons between ketoconazole and other antifungals were based on single studies that showed comparability of treatment effects. CiclopiroxCiclopirox 1% led to a lower failed remission rate than placebo at four weeks of follow-up (RR 0.79, 95% CI 0.67 to 0.94, eight studies, moderate-quality evidence) with similar rates of side effects (RR 0.9, 95% CI 0.72 to 1.11, four studies, moderate-quality evidence). Other antifungalsClotrimazole and miconazole efficacies were comparable with those of steroids on short-term assessment in single studies.Treatment effects on individual symptoms were less clear and were inconsistent, possibly because of difficulties encountered in measuring these symptoms.Evidence was insufficient to conclude that dose or mode of delivery influenced treatment outcome. Only one study reported on treatment compliance. No study assessed quality of life. One study assessed the maximum rash-free period but provided insufficient data for analysis. One small study in patients with HIV compared the effect of lithium versus placebo on seborrhoeic dermatitis of the face, but treatment outcomes were similar. Authors' conclusions: Ketoconazole and ciclopirox are more effective than placebo, but limited evidence suggests that either of these agents is more effective than any other agent within the same class. Very few studies have assessed symptom clearance for longer periods than four weeks. Ketoconazole produced findings similar to those of steroids, but side effects were fewer. Treatment effect on overall quality of life remains unknown. Better outcome measures, studies of better quality and better reporting are all needed to improve the evidence base for antifungals for seborrhoeic dermatitis.
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The Nature of Dandruff
Article
Dandruff is excessive clinically noninflammatory scaling of the scalp. In the great majority of cases, diagnosis can be made almost instantly by simply inspecting and scratching the surface. Lesions elsewhere on the body call at- tention to disorders which also happen to involve the scalp, notably seborrheic dermatitis and psoriasis. Difilculties arise when the latter are chiefly confined to the scalp for inflammatory changes are masked in this location. Scalp skin is thick and redness and exudation may be hidden by layers of scale. Scaling itself is a very nonspecific sign. Great experience is needed to recog- nize the special morphologic qualities of different dermatoses, viz., the silvery scale of psoriasis or the greasy scale of seborrheic dermatitis. We always in- quire about past and present skin disease. Wrong diagnoses, while not common, are frequent enough to cause some mischief. It is disquieting how often we have mistaken another process for dandruff, most often seborrheic dermatitis in older subjects. Diagnostic er-
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Dandruff: The most commercially exploited skin disease
Article
  • Apr 2010
The article discuss in detail about the prevalence, pathophysiology, clinical manifestations of dandruff including the etio-pathology. The article also discusses in detail about various treatment methods available for dandruff. The status of dandruff being amphibious - a disease/disorder, and relatively less medical intervention is sought after for the treatment, dandruff is the most commercially exploited skin and scalp disorder/disease by personal care industries.
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Medicated shampoos for the treatment of seborrheic dermatitis
Article
  • Aug 2008
Seborrheic dermatitis is a common papulosquamous disorder of the skin, affecting 3% to 5% of the population. Dandruff, a less severe form of seborrheic dermatitis, affects a greater proportion of the population. The exact pathogenesis of seborrheic dermatitis is unknown, however colonization of the lipophilic yeast, Malasezzia furfur, and an inflammatory reaction to this yeast each seem to play a role in disease etiology. Therefore, treatment for seborrheic dermatitis is aimed at yeast elimination and inflammation control. Several treatment modalities are available for seborrheic dermatitis and dandruff including shampoos, which contain both active ingredients related to antimycotic or anti-inflammatory effects and also surfactant ingredients that allow these shampoos to replace regular shampoos in affected patients. The literature regarding the treatment of therapeutic shampoos is reviewed, and treatment strategies for managing seborrheic dermatitis with therapeutic shampoos are provided.
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Handbook of cosmetic skin care
  • Jan 2001
  • A Shai
  • Hi Maibach
  • R Baran
Shai A, Maibach HI, Baran R. Handbook of cosmetic skin care. 1st edition. London: Martin Dunitz Co; 2001.