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PHARMACOLOGY / COSMETOLOG Y

The treatment of dandruff


of the scalp
prof. dr hab. med. Zygmunt Adamski*/**, lek. med. Magorzata Deja*/**
*Department of Medical Mycology and Dermatology, Pozna University
of Medical Science
Director: prof. dr hab. med. Zygmunt Adamski
**Provincional Hospital in Pozna, Department of Skin Diseases
Head: prof. dr hab. med. Zygmunt Adamski

Introduction changed and no excessive hair loss related to humoral and cell immu-
is observed. nity, proved by associated severe se-
Term dandruff pityriasis, In the epidermis of people suffe- borrhoeic dermatitis often observed
meaning bran-like epidermal sca- ring from common dandruff histo- in subjects infected with HIV or
ling (Greek pityron: bran-like) was pathology analysis reveals characte- suffering from AIDS; disorder is
introduced into dermatological vo- ristic intervals of parakeratosis foci, present in a significant proportion
cabulary by Galen [1]. Disease con- raised mitotic index of corneocytes of this group of patients (even 34-
stitutes a very widespread problem, and peeling in the form of multice- -83%) [5];
present in more than a half of po- llular aggregates; there is no actual - hormonal factors, related to
pulation of Caucasian origin [2]. inflammatory status of the proper the fact, that lesions appear more
Although most commonly it is skin [4]. commonly in younger males (du-
a problem of just aesthetic nature, The other form of the disorder is ring puberty) and in young adults,
chronic character of this condition so called oily dandruff (Pityriasis when sebum glands function is
and tendency to relapse makes it steatoides), being just the form of most intensive and androgen level
troublesome and difficult to cope dandruff arising on the scalp skin increases,
for people suffering from this con- with varied intensity of sebum pro- - neurological abnormalities
dition. Two types of dandruff can duction. It appears most often in (during depression, also in cases of
occur common (dry) or oily dan- young men following puberty (aged Parkinson disease),
druff. between 18 and 24). On the skin of Cited exogenous factors include:
Common (dry) Dandruff (Pity- the scalp area inflammation of va- - lifestyle (incorrect skin care,
riasis simplex capiliti s. sicca, furfura- rious intensity then develops, con- mikrotrauma and stress),
cea) is characterised by excessive stituting the basis for fragile, oily - diet factors (poor nutrition, al-
formation of minute scales of scales (Pityriasis oleosa) of dirty-ye- coholism),
whitegreyish or ashen colour, accu- llow colour, which can form accu- - environmental factors (envi-
mulating on the scalp area. These mulations. These lesions can be ronmental pollution and climate)
bran-like scales are at first localised associated with pruritus of various [5,11,12].
in the middle of the scalp area and intensity [3].
then spread towards, parietal, fron- The aetiology of dandruff, being Seborrhoeic dermatitis can also
tal and occipital areas [3]. the form of seborrhoeic dermatitis, be associated with the presence of
Scales visible on the scalp are se- is not unequivocally established. other diseases including: pancreati-
parated cells of keratinised layer, Many factors are usually listed, de- tis, HVC infection, neoplasms and
whose renewal cycle is pathological- scribed as endogenous and exoge- also genetic abnormalities (for
ly shortened (even to 7 days, with nous. Researchers include the follo- example Down syndrome, Hailey-
the norm equalling 28 days). Hair wing into the first group: -Hailey disease) [5].
in this type of dandruff are not - immunological abnormalities, Regardless of such multifactor

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etiopathogenesis of the disease, the


greatest significance is believed to The treatment of dandruff
be associated with lipophilic yeast
Malassezia furfur (Pityrosporum ovale,
of the scalp
Pityrosporum orbiculare) infection. SUMMARY
This thesis, regarding the explana- Key words: dandruff of the scalp, dermatitis seborrhoica, clinical trials, treat-
tion of scalp skin peeling was pro- ment of dandruff, zinc pyrithione, imidazole agents, tar, octopirox, salicylic
posed already in 1874 by Malassez acic, urea, sulfur
[6]. Since that time great many Dandruff of the scalp is a very common problem in aesthetic dermatology. The
number of trials have been perfor- pathogenesis of dandruff is connected with an infection with a yeast-like fungus
med in order to confirm or negate Malassezia furfur and with shortend proliferation cycle of keratinocytes which
causes abundant epidermis desquamation on the skin. There are two forms of
the thesis. It has been noted, that
dandruff sicca or steatoides.
increased number of this yeast-like The aim of this article is to present dandruff treatment methods with a special
population present on the scalp emphasis on modern antidandruff products which are devided into three
skin disturbs its ecosystem, ena- groups due to their mechanism of activity (antifungal agents, keratolytic agents
bling development of the disorder. and cytostatic agents). The comparison of efficiency of these products based
on results of worldwide clinical trials is presented to propose physicians the
Lipophilic yeast-like constitute just
best possible therapy.
46% of scalp microflora in healthy The most efficient drugs and thus mainly used are shampoos including antimy-
subjects, whereas in dandruff their cotic agents that eliminate Malassezia furfur from the scalp. The most widely
number increases to 74%, and in antimycotic shampoos used in dandruff therapy are products with ketocona-
cases of seborrhoeic dermatitis zole and zinc pirythione. However, the risk of developing yeast species resistent
to imidazole agents has to be taken under consideration while treatment.
even to 82% [7]. In studies by
Antidandruff products such as keratolitic and cytostatic agents work only symp-
Adamski, where classic mycological tomatically, and often recurrence of dandruff after stopping treatment
methods were used, presence of is observed. It is a reason why these groups of agents are recommended
Malassezia furfur was shown in in politherapy of dandruff of the scalp. Octopirox is efficient, antidandruff cyto-
22% of subjects in the control gro- static agent with additional antibacterial and antimycotic activity.
The important role of proper skin treatment, prophylactic and metaphylactic
up, in 55% patients with scalp dan- methods should always be remember in dandruff treatment.
druff and 40% of patients with se-
borrhoeic dermatitis [8]. Additio-
nally in patients with oily steatic not find differences in the content Chamomillae), soapwort roots (Rad.
dandruff high level of serum anti- of Malassezia furfur in disease le- Saponariae) or burdock roots (Succ.
bodies against Pityrosporum was sions as compared to healthy skin Bardanae). Herbal treatment invo-
found [9]. Association between [14]. It is clearly visible then, that lves also use of complex formulas
a yeast infection and disease patho- the problem of etiopathogenesis of such as Betulan (birch leaves, ca-
genesis was also confirmed by seborrhoeic dermatitis and dan- momile capitules, yarrow herb, Pot
improvement observed following druff is till causing a lot of contro- Marigold pellets and lavender pel-
treatment with fungicidal drugs versy and is vividly discussed. lets) or Seboren (parsnip fruits, net-
[1,10,11]. While the new genera- In severe cases of seborrhoeic tle roots, burdock roots and sweet
tion of drugs was being developed dermatitis differential diagnosis flag rhizome) [15].
interest in the infection with Mala- should consider other diseases such The rules of pharmacological
ssezia furfur and its association with as, scalp psoriasis, fungal infection, treatment of dandruff were summa-
aetiology of seborrhoeic dermatitis some forms of ichthyosis, and also rised and codified in Consensus of
flourished. It was observed, that in asbestos dandruff (Pityriasis amian- the expert group of Polish Derma-
patients treated with ketoconazole tacea) [3]. tological Society Mycological Sec-
apparent improvement of clinical Considering the fact, that scalp tion on dandruff therapy. Accor-
status was associated with the re- dandruff is a chronic and relapsing ding to the mechanism of action
duction of the number of Malassezia condition, the question of proper the recommended formulas were
yeasts within disease lesions. Some treatment has been widely analy- classified into three groups:
authors showed, that Malassezia sed. Effective pharmacological for- 1) fungicidal substances (zinc
fungi are more commonly found in mulas were sought, also therapeutic pirythioniate, imidazole formulas
patients with dandruff and sebo- use of herbal substances was tried, for example ketoconazole),
rrhoeic dermatitis than in healthy for example nettle leaves (Folium 2) cytostatic substances (tar, se-
subjects [5,13]. Others however do Urticae), camomile pellets (Anth. lenium sulphide, octopirox),

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PHARMACOLOGY / COSMETOLOG Y

3) keratolytic substances (tar, or 1% ketoconazole and further pe- ketoconazole and other antidan-
salicylic acid, urea, sulphur com- riod of consecutive 4 weeks without druff substances. Multicentre, ran-
pounds). therapy. Effectiveness of therapy domised trial by Pierard-Franchi-
was assessed on the basis of clinical mont et al., evaluating use of
picture, mycological tests, showing a shampoo containing 2% ketoco-
Fungicidal substances presence of Malassezia spp. and pee- nazole or 1% zinc pirythioniate in
ling measurements (scales measure- a group of patients with severe scalp
Considering confirmed influence ments). Following 4 weeks of treat- dandruff can serve as an example.
of Malassezia yeasts on development ment shampoo containing 2% of The results of the trial confirmed
of dandruff, fungicidal formulas are ketoconazole proved to more effica- the effectiveness of both shampoos,
widely used in therapy of this con- cious than shampoo with 1% con- however better therapeutic effect
dition and are characterised by centration. Lesser tendency to expe- was noted in the group applying
great therapeutic effectiveness. It rience disorder relapses was also no- 2% ketoconazole (improvement of
can even be said, that introduction ted during the period of use of 2% 73%) as compared with the group
of fungicidal drugs, for example imi- shampoo [16]. applying 1% zinc pirythioniate (im-
dazole derivatives ketoconazole, A multicentre, randomized trial provement of 67%). The percentage
econazole etc., zinc pirythioniate with double blind placebo control- of disease relapses was also lower
and selenium sulphide constituted led outlay including 575 patients in the group using 2% ketocona-
a break-through in the therapy of has been organised, in which effec- zole [18].
dandruff. These compounds are tiveness of introducing a shampoo In another randomised trial with
a group of drugs with etiological ac- with 2% ketoconazole in therapy blind setting efficiency of using two
tion, inhibiting the growth of Ma- and prophylaxis of moderate and shampoos was assessed: one con-
lassezia furfur. severe dandruff was assessed. Very taining 2% ketoconazole and the
good therapeutic results were achie- second one, containing 1.5% cyclo-
Ketoconazole is an imidazole ved in 88% of patients. Prophylac- piroxolamine and 3% salicylic acid,
derivative of wide fungicidal spec- tic phase fo the trial lasting for 6 in the course of treatment of scalp
trum, which mechanism of action months revealed disease relapse in seborrhoeic dermatitis. This study
involves inhibition of biosynthesis only 23% of patients using ketoco- confirmed effectiveness and safety
of ergosterole (P-450 cytochrome) nazole, while relapse occurred in of therapy employing any of tested
within the fungal cell wall, causing 47% of patients in the placebo shampoos [19].
its altered permeability and conse- group. Results proved effectiveness Danby et al. completed randomi-
quently death of a cell. Ketoconazo- of using shampoo with ketoconazo- sed double blind placebo controlled
le displays also anti-inflammatory le 2% in the treatment and prophy- clinical trial involving 246 patients,
action through inhibition of 5-lipo- laxis of relapsing dandruff [17]. in whom effectiveness of a shampoo
oxygenase and leukotriene B4 pro- Also in Polish studies performed with 2% ketoconazole was compa-
duction, as well as antiandrogen ac- by Adamski, effectiveness of thera- red with shampoo containing 2.5%
tion. Used topically also relieves py of scalp oily dandruff in 40 pa- selenium sulphide in treatment and
prurigo and decreases intensity of tients applying 2% ketoconazol was prophylaxis of moderate and severe
skin lesions present in the course of assessed. Following 4 weeks of treat- dandruff. This study showed thera-
seborrhoeic dermatitis, common ment the number of positive myco- peutic effectiveness of both tested
dandruff and pityriasis versicolor. logical tests decreased from 55% to shampoos disclosing at the same
Numerous clinical trials confirmed 7%. In further tests still greater re- time, that shampoo with 2% keto-
therapeutic effectiveness of ketoco- duction of clinical symptoms and conazole was better tolerated by pa-
nazole in these diseases. signs in the form of prurigo, peeling tients [20].
In a randomized trial including and erythema was observed. Thera- In the therapy of dandruff em-
66 subjects effectiveness of applica- py efficiency reached 75%. Achie- ployment of other, apart from keto-
tion of shampoos containing 1% ved results confirmed the important conazole, imidazole derivatives (for
and 2% ketoconazole in treatment role of Malassezia furfur in scalp dan- example flutrimazole, econazole, bi-
of severe dandruff and scalp seborr- druff etiopathogenesis and effec- fonazole, clotrimazole) is possible.
hoeic dermatitis was weighed. The tiveness of fungicidal therapy of A randomised double blind clinical
trial included a few stages: period of this condition [8]. trial was performed comparing effe-
2 weeks before treatment, period of Numerous clinical trials were ctiveness of 1% flutrimazole in the
4 weeks of using shampoos with 2% performed comparing application of form of a cream with 2% ketocona-

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zole for treatment of Candida spp. shampoos incorporating 2% ketoco- Effectiveness and therapy safety
and dermatophytic infections, nazole and 1% zinc pirythioniate associated with climbazole use was
which proved, that these formulas versus placebo. The above listed for- confirmed by the study prepared
are at least equally effective. Addi- mulas were used in 364 patients by Wigger-Alberti et al., which
tionally flutrimazole displays also with moderate and severe dandruff involved testing shampoo conta-
anti-inflammatory action, which through the period of 4-6 weeks. ining 0.65% climbazole in a group
makes it more useful in cases of bac- The trial has proven comparable of 30 people with mild and mode-
terial infection associated with in- therapeutic effectiveness of both rate scalp seborrhoeic dermatitis.
flammatory reaction [21,22]. formulas [25]. Following 4 weeks of treatment re-
It must be however remembered, Samplea et al. organised a study duction of dandruff was observed,
that widespread use of imidazole involving 236 patients with mode- receding of the erythema and pruri-
derivatives can in a long term cause rate and severe dandruff, in whom go was confirmed in 80% of tested
increased resistance of Malassezia a shampoo with ketoconazole 2% subjects, in the remaining 20% im-
yeasts to the formulas used and ma- and zinc pirythioniate 1% was used provement of the skin status was
ke therapy of not only dandruff, but for a period of 4 weeks. The results noted [29].
also more severe fungal skin infec- included significant improvement
tions more difficult. of the skin status, disease symptoms
reduction of even 90%, comprising Cytostatic substances
Zinc pirythioniate is a further receding of prurigo and erythema.
substance displaying fungicidal acti- Shampoo with ketoconazole 2% Substances from this group act
vity, useful in eliminating Malassezia and zinc pirythioniate 1% turned through regulation of the excessive
furfur. Mechanism of action of this out to be safe and efficient way of speed of epidermal cells division in-
substance involves inhibition of cell treating dandruff [26]. hibiting exaggerated peeling of the
wall transport in the fungal cell The test of popular antidandruff scalp area, thus eliminating the
(probably by inhibiting proton shampoo was performed showing, scales, being the basic feature of
pomp), what in effect leads to lysis that formula with 1% ketoconazole dandruff. The above mentioned
of fungal cells. It has been shown, is 10-times more efficient than group includes: tars, selenium sul-
that apart from described fungicidal other competing shampoos (asses- phide and piroktolamine (octopi-
action, this formula influences ul- sed versus Head & Shoulders, Pan- rox). These substances action is ho-
trastructure of epidermal layer cells, tene Blue, Gard Violet, Selsun wever restricted only to the period
enabling its normalization [23,24]. Blue), while shampoo with 2% keto- of actual use, meaning that after
It should also be stressed, that zinc conazole is 10-times more efficient cessation of treatment relapses of
pirythioniate is characterised by its than the one containing 1% [27]. the disease are quite often noticed.
significant lipid solubility, dissolves It can be explained by symptomatic
in sebum, thus the period when While discussing fungicidal sub- only action of these formulas and
effective concentration of the for- stances recommended for treatment lack of aetiological effect associated
mula is maintained in keratinized of dandruff, attention must be paid with insignificant influence on the
epidermal layer is prolonged achie- to new formulas currently at the sta- population of Malassezia furfur [15].
ving increased fungicidal activity. dium of clinical research; these inc- Formulas containing selenium
Azole substances on the other hand, lude: rilopirox, climbazole and li- sulphide are also recommended in
contrary to zinc pirythioniate, are thium succinate [12]. The above li- the treatment of the form of dan-
hydrophilic compounds and do not sted formulas for local use arise druff (pityriasis versicolor). Sele-
accumulate in lipophilic environ- wide interest as a new therapeutic nium sulphide has a cytostatic eff-
ment of Malassezia furfur, what options. There are also trials curren- ect on epidermal and hair follicles
explains required prolonged period tly running evaluating effectiveness cells, inhibiting excessive peeling,
of treatment if azole based drugs are of the above substances in the elimi- redness and prurigo. It also exhibits
employed [15]. nation of Malassezia furfur. antifungal activity inhibits deve-
Numerous clinical trials were In the study by Harady et al. asse- lopment of dermatophytes, which
performed evaluating effectiveness ssing in vitro antifungal activity of cause proper mycoses of epidermis,
of shampoos containing zinc piry- rilopirox it was shown that the new hair and nails. However, it must be
thioniate and comparing it with formula displays a wide range of remembered, that regular use of for-
other formulas. An example of such fungicidal activity, comparable with mulas containing selenium sulphide
trials was multicentre evaluation of cyclopiroxolamine spectrum [28]. can give rise to excessive produc-

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tion of sebum and oily hair [30]. six weeks of therapy reduction of development of yeasts and bacterial
dandruff symptoms by 54.5% was skin flora. For treatment of dan-
Octopirox is a pyrydinone deri- achieved in subjects using octopirox druff use of the shampoo 2-3 times
vative of a proven effectiveness in and by 9.9% in subjects applying a week for a period of 4-6 weeks is
dandruff treatment, used since placebo [32]. A comparative effecti- recommended, followed by prophy-
1977. In recommended therapeutic veness study was performed invo- lactic routine, meaning use of the
shampoos preferred concentration lving shampoo containing piroktola- formula containing ketoconazole
of this substance ranges from 0.5% mine 0.75% in association with 2% 1% only.
to 1.0%. A wide range of antibacte- salicylic acid versus shampoo conta- At present use of a shampoo con-
rial and antifungal action of octopi- ining 1% zinc pirythione. Both taining 1.5% cyclopiroxolamine is
rox has been shown in in vitro stu- shampoos displayed high effective- recommended in the treatment of
dies. Its effectiveness and safety of ness against dandruff, however dandruff along with pyrydinone
therapy was confirmed in the clini- shampoo containing both ingre- derivative, which shows fungicidal
cal studies: in over 200 volunteers dients seemed to be more efficient and fungostatic action (towards der-
using formulas containing octopirox in eradicating symptoms of dan- matophytes, yeast-like fungi, mould
no signs or symptoms of irritation, druff [33]. and dimorphic fungi), antibacterial
allergy or other toxic reactions were (Gram positive, Gram negative bac-
observed. Octopirox formulas of A very interesting formula intro- teria) and anti-inflammatory action
0.5% concentration are also effec- duced for therapy of dandruff is (greater than 2.5% hydrocortisone)
tive in prophylaxis [31]. a therapeutic shampoo Mediket [23]. Mechanism of antifungal
In the trial by Futterer effective- Plus. This product contains two the- action of the formula is different
ness of the formula containing octo- rapeutic substances: ketoconazole from the mechanism of action of
pirox in the concentration of 0.75% 1% characterised by antifungal ac- imidazole derivatives drug accu-
was compared with placebo. After tion and octopirox 1% restricting mulates in the fungal cells, binds to
its organellae, thus causing inc-
reased permeability of the cell mem-
Table 1 brane, escape of nutrients and
Examples of the products used in the treatment of dundruff blocking of enzymatic processes. All
the above leads finally to death of
fungal cells [34].
ketoconazole 2% (Nizoral, Nizoxin)
Gullon et al. performed tests
ketoconazole 1% (Nizorelle, Mediket, Mediket Plus)
comparing effectiveness of anti-dan-
Imidazole clotrimazole (Triazol)
formulas flutrimazole (Micetal gel) druff therapy using two shampoos:
econazole (Pevaryl) with 1.5% cyclopiroxolamine and
bifonazole (Mycospor) 2% ketoconazole. Study results sho-
wed stronger action of anti-dandruff
Zinc therapeutic shampoos: firmy Head & Shoulders, Polytar AF,
shampoo with 1.5% cyclopiroxo-
pirythione Ocerin PTZ, Squa-med, Freederm, Zinc Shampoo, Satinique
lamine [33]. It has been proved
tars (Polytar Liquid, Neutrogena T-Gel, Freederm) that, shampoo with 1.5% cyclopiro-
Cytostatic selenium sulphide (Selsun Blue) xolamine is a modern, effective for-
formulas piroktolamine (Octopirox, Dercos, Ocerin OPX) mula well tolerated by patients
1.5% cyclopiroxolamine (Stieprox)
[34].
Study by Lee et al. involved com-
Keratolytic Cocois: tar, precipitated sulphur, salicylic acid, coconut oil
parison of effectiveness of the sham-
substances Provictiol: urea and salicylic acid
poo containing 1.5% cyclopiroxola-
mine with shampoo containing 2%
Ocerin PTZ: urea, undecenoic acid derivative and zinc
ketoconazole in treatment of mild
pirythioniate
and moderate dandruff. Study in-
Complex Ocerin OPX: urea, undecenoic acid derivative and octopirox
Saliker: i.a. salicylic acid and piroktolamine cluded 64 patients. It was observed
formulas
Mediket Plus: contains ketoconazole 1% i octopirox 1% that dandruff intensity decreased
Kerium during use of both formulas. Only
a mild degree of increased perceived
scalp itching was observed in III

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phase in people using 1.5% cyclopi- licylic acid, 0.75% piroctolamine Shampoos with anti-fungal ac-
roxolamine. Conclusions: cyclopiro- and 0.5% elubiol), showed lack of tion, listing ingredients such as ke-
xolamine is an effective, safe and statistically valid differences of the toconazole and zinc pirythione are
easy to use substance in the treat- relevant formulas effectiveness. believed to be the most effective
ment of mild and moderate dan- Both drug groups were assessed as and their effectiveness tested in nu-
druff [35]. formulas achievement high percen- merous clinical trials seems to be
tage of improvement, of even 70% comparable. Whereas action of ke-
and more. Shampoo containing sa- ratolytic and cytotoxic formulas is
Keratolytic formulas licylic acid, piroctolamine and elu- only symptomatic, relying on elimi-
biol appeared to be more efficient nation of visible scales from scalp
Keratolytic formulas, whose ac- in achieving reduction of a popula- skin. Thus, after cessation of treat-
tion relies on removal of scales of tion of Malassezia spp. [36]. ment with these formulas the relap-
epidermal keratinised layer include: se of disease is quite commonly ob-
salicylic acid, urea, tars, and sulphur served. Keratolytic and cytotoxic
derivatives. The last ones are re- Summary drugs are ingredients of complex
commended as part of combined formulas and are mainly recommen-
therapy, for example with anti-fun- In the modern world much ded for use in complex therapy of
gal substances, because of their attention is paid to the way other scalp dandruff.
short-lived, symptomatic-only the- people look (external features), Considering chronic and relap-
rapeutic effect. which quite often helps or hampers sing character of the disease, proper
There are also a number of for- realisation of their plans or projects. care of the scalp and prophylaxis
mulas containing tar (commonly A very fast development of aes- cannot be forgotten, as they are of
together with salicylic acid). Older thetic medicine or cosmetic derma- immense significance in the eventu-
tar formulas were recognisable by tology is an adequate response to al success of therapeutic process,
their unpleasant smell and dark co- the social need to improve ones thus also in achieving patient satis-
lour. Modern, presently used for- appearance enabling also better self- faction.
mulas do not feature those unple- assessment.
asant characteristics, because frac- Problem of dandruff, sometimes Numerous formulas recommen-
tions of aromatic hydrocarbons, re- underestimated by medical profes- ded for dandruff treatment are
sponsible for the negative features sionals constitutes a problem for currently available on the market,
of the discussed above formulas a large chunk of society. The aspects however therapeutic result achieved
were eliminated. of treatment presented in the artic- is strongly associated with adequate
There are no sufficient number le herein, therapeutic novelties and patient comprehension of an actual
of trials assessing effectiveness of results of numerous comparative cli- problem and disease aetiology. The
anti-dandruff treatment shampoos nical studies prove, that dandruff actual task of the physician is to
containing tar. One of the trials treatment is not as simple an issue make patient aware of the necessity
comparing effects of the products as would at first appear. Regardless of regular use of recommended the-
containing tar (0.5%) and sham- of the existence and widespread use rapy and of the need to continue it
poo, which did not list tar as ingre- of numerous therapeutic substances even after external symptoms of the
dients (ingredients included: 2% sa- disease relapses are common. disease have disappeared.

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Zygmunt Adamski
Oddzia Chorb Skry z Zespoem Pomocy Doranej
Szpital Wojewdzki
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Phone: 048 61 821 23 08, 048 61 821 22 52
E-mail: adamskiz@poczta.onet.pl

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