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When you see your kid scratching their head, your gut instinct might be to grab head lice shampoo. But itching can mean tons of things, ranging from the superficial to the serious. So how do you solve the mystery of your kid’s itchy scalp? And the time-honored question: how do you stop scratching when it feels sooooo good?
Read the transcript:
Dr. Angela Mattke: This is “Mayo Clinic Kids,” a podcast from Mayo Clinic where we discuss the latest pediatric research and recommendations to help keep your kids laughing and thriving. I’m Dr. Angela Mattke, a pediatrician with Mayo Clinic in Rochester, Minnesota. This episode, we’re talking about itching.
Dr. Angela Mattke: Molly, have you ever seen a patient in clinic who’s constantly itching their body, or maybe they have some type of illness, disease, or infection that is causing their scalp to be really, really itchy? And all of a sudden you’re trying not to itch your scalp, but it’s driving you crazy?
Dr. Molly Youssef: Yes, definitely. I would say that’s relatively common in dermatology clinics. We see lots of patients who are incredibly itchy—scratching their skin or scalp to the point of bleeding. The residents and I, upon leaving the room, are finding ourselves washing our hands, feeling like we’re scratching ourselves.
Dr. Angela Mattke: I have definitely seen patients with head lice or bed bugs in my clinic and I can’t stop itching myself the entire day, and I feel like it’s all in my head. Do you know anything about that? Is that a real thing?
Dr. Molly Youssef: It is a real thing. So when one person is scratching, another person feels like they need to scratch as well. It’s like the contagious effect of yawning. Someone yawns and pretty soon everyone yawns. And man, I hate it when I start yawning in front of my patients.
Dr. Angela Mattke: See, I want to yawn now!
Dr. Molly Youssef: Yes, me too!
Dr. Angela Mattke: When you see your kid scratching their head, your gut instinct might be to reach for your keys to go get head lice shampoo. But itching can be a symptom of tons of things, ranging from the superficial to the serious. How do you solve the mystery of your kid’s itchy scalp? And what can you treat at home, versus going to see a doctor? And of course, the time-honored question: how do you stop scratching when it feels so good? Because surely the answer isn’t duct-taping oven mitts to your kid’s hands.
Before you start scratching your own head in confusion, we’re talking with Dr. Molly Youssef. Molly is a pediatric dermatologist at Mayo Clinic in Rochester, Minnesota, where she treats a whole range of skin conditions in kids. She’s here to help us learn why your kid might be scratching their head, and how to find relief.
Thanks so much for joining us today, Molly.
Dr. Molly Youssef: Thank you, Angie. It’s a pleasure.
Dr. Angela Mattke: Molly, as we just talked about, we’ve all experienced itching, whether it’s actually you and I in clinic seeing a patient who’s having lots of itchy rashes, but what actually causes it? What is happening in the nerves and the skin cells that makes us want to scratch our skin away sometimes?
Dr. Molly Youssef: It’s known that itch is due to a specific type of nerve called C nerve fibers. These are actually slower transmitting nerves, but they’re found in the skin and they transmit sensation to the spinal cord and the brain, and actually there’s different types of C nerve fibers. Some of them are more stimulated by a chemical called histamine that we have in our body. It’s thought that those nerves actually drive the itch that is histamine triggered, such as itch that occurs with hives and more acute type itch, so itch that develops very rapidly.
Then there’s chronic itch or itch that’s been occurring for months or years that some patients experience. That type of itch is thought to be related to nerves that are not triggered by the histamine chemical. Then it makes sense why some types of itch respond to the antihistamine medications and some don’t.
Dr. Angela Mattke: Does that have any part in why it feels so good to scratch that itch sometimes?
Dr. Molly Youssef: Yes. So the nerves that play a part in driving that itch [and] transmitting that itch feeling connect to the spinal cord and brain. Then when you actually scratch, some endogenous opioids in the body, another type of chemical in the body, are released.
Opioids are our reward. Chemicals in the body, And that’s why when we itch, it feels really good and we want to keep scratching.
Dr. Angela Mattke: As a parent, is an itch always a cause for concern? Because if one of my sons says to me that their head is starting to itch today after school, how seriously should I take this? Should I be freaking out? Starting to look for lice?
Dr. Molly Youssef: You don’t have to start freaking out right away. It’s certainly reasonable to take a peek at their scalp, of course. See if anything looks unusual to you. And then you can kind of go from there, but it’s just so common, it might just be something that’s going to be occurring for a day or two and then resolve. We can talk further about things to look for, for parents.
Dr. Angela Mattke: Is there something that tips you off that it’s more than just an itch that we can fully ignore, and see if anything comes of it? Or is there something on their scalp, a certain appearance that maybe should prompt you to reach out to one of your medical providers?
Dr. Molly Youssef: If there’s true blisters on the scalp, like fluid-filled bumps that are either filled with clear fluid or filled with pus looking fluid, that would be a reason to see a doctor. Also, if there’s a lot of drainage or crusting on the scalp as well, it might be a sign of infection.
If there’s areas of the scalp that overall feel what we call boggy—kind of squishy—that would be really unusual. And if you notice a lot of enlarged lymph nodes in your child’s neck, or you’re seeing lumps on the back of their neck or front of their neck, that might mean that there’s an infection or another issue going on in the scalp as well. One other factor is the degree of itch. If the child is just incessantly, persistently scratching their scalp, and that’s creating bleeding or scabs or difficulty focusing at school, that would be another reason to have them evaluated.
Dr. Angela Mattke: So itching is obviously a really common symptom, but we always want to figure out what the cause is. Let’s go over some of those categories that can cause itching, starting with those skin issues. What are some of the common skin conditions that cause itching?
Dr. Molly Youssef: When we’re specifically talking about the scalp, seborrheic dermatitis is one that comes to mind right away. It’s a condition of the scalp otherwise known as dandruff, but it can range from mild, white flaky dandruff to more severe scalp inflammation with a lot of the redness and the thicker scales.
Sometimes we even see so much scale starting to suffocate the hair follicle to the point that the patient is having hair loss and a lot of pain of the scalp. That’s a common skin condition of the scalp. Of course, itching also occurs commonly in kids due to eczema, also known as dermatitis.
Eczema commonly occurs in babies on the elbows, knees, and face, and then in older kids, on the crooks of the arms, the back of the knees, those types of areas—hands and feet as well. Kids with eczema are actually prone to having dermatitis of the scalp as well.
Psoriasis is another condition that is commonly seen on the scalp. It looks a little bit different because the plaques are what we call more well-defined. There’s a definite start and stopping point and they’re thicker pink areas with a lot of silvery scales.
Dr. Angela Mattke: It sounds like the psoriasis tends to be more distinct, separate plaques where you can see the edge it starts. Seborrheic dermatitis, or dandruff—can it be all over the scalp or can it just be parts of the scalp? What would be a visual sign to help distinguish between eczema of the scalp versus seborrheic dermatitis or dandruff?
Dr. Molly Youssef: It can be a little bit tricky to distinguish and there can be some overlap. Eczema of the scalp sometimes looks a little more like severe dryness of the scalp with a lot of flaking, but that can also, [correlate] with the appearance of seborrheic dermatitis.
One of the classic appearances of seborrheic dermatitis though, is having a little bit more of a yellowish greasiness to the scale, so that can help to set apart. The seborrheic dermatitis a bit more. But it is true. Seborrheic dermatitis can occur in various areas of the scalp and move around. It can occur around the ears and on the ears, so that can also be a clue. Regular eczema can occur on the ears as well.
Dr. Angela Mattke: Does any of a child’s history help you, if it’s a tricky case to sort between eczema or seborrheic dermatitis? Or does it really not matter what exactly the cause of it is because you can do a treatment that would cover both.
Dr. Molly Youssef: When there’s a history of eczema in the child, then it’s more likely to be eczema of the scalp. It’s relatively rare for people to have an isolated eczema of just the scalp and not elsewhere on their body, unless they have a contact eczema to something they’re using on their scalp.
If they’ve developed an irritation or an allergy to a product, then they might have eczema just on the scalp. Usually kids with eczema on the scalp have eczema on the rest of their body in some form as well. Overall, the treatments are fairly similar, with specific shampoos that we can recommend and some other topical treatments.
Dr. Angela Mattke: Well, let’s talk a little bit about those treatments. Does it seem reasonable for parents to try some at-home stuff before they reach out to their doctor or see the dermatologist?
Dr. Molly Youssef: Definitely. One of the things we hear often is that, when the child’s scalp is looking kind of flaky, parents are worried that it’s dry. They start to wash the child’s hair less frequently. That typically worsens the problem. If there’s seborrheic dermatitis going on, we recommend actually washing the hair more often, ideally every day if possible.
And then, parents can try over-the-counter anti-dandruff shampoos as a first step for seborrheic dermatitis, and sometimes can help with regular eczema as well. Some of the over-the-counter shampoos contain selenium sulfide, zinc pyrithione, and ketoconazole as well. Ttypically each product has one of those ingredients or two, but it’s helpful for parents to maybe buy two different shampoos and rotate them, so that there’s more than one ingredient that might help the scalp and they can use one shampoo each day.
Dr. Angela Mattke: I just chuckled to myself as you rattled off those really hard to say names with no problem whatsoever. So that’s how you say it, didn’t know that! Hopefully I’m saying them correctly.
How serious are these conditions? More importantly, I think parents always wonder, if I don’t do anything about it, is this going to cause long-term consequences for my child if left untreated?
Dr. Molly Youssef: No. When we’re talking about seborrheic dermatitis or eczema of the scalp, it’s not going to typically cause long term harm—unless there we’re talking about severe, deep scratching that could lead to scarring or something along those lines, or if there’s infections occurring. But overall it’s common that I incidentally find, “Oh, you have some dermatitis here.” And the patient’s like, “Oh, you know, my scalp isn’t itchy. Nothing’s going on.” And, I say, “Well, if you want to try an over-the-counter anti-dandruff shampoo, go ahead.” But most of the time, patients, if it’s not bothering them, often elect to not even treat. No long term consequence if it’s not bothering the patient.
Dr. Angela Mattke: Why do kids feel itchy in the first place? Well, we all have C-nerve fibers that, when triggered by histamine, transmit those itchy sensations up the body. Then we have other nerves that transmit other types of itching—chronic and long term itches.
Itching is not always a cause for concern. It might just be a passing sensation. But if your kid has blisters, or signs of infection like drainage, crusting, bogginess or enlarged lymph nodes, make sure to get them evaluated. Same goes if there’s a high degree of itching.
Your child might experience itching due to dandruff, seborrheic dermatitis, or eczema. These typically aren’t cause for worry. If you think your kid might have one of these and it’s affecting their scalp, feel free to start treating with an anti-dandruff shampoo. You can try using two alternating products with different ingredients to see what sticks.
Like I mentioned earlier, I think a lot of parents automatically jump to itchy scalp equates to head lice and oh my gosh, what are we going to have to do to treat this?
I think that’s the one most of us are pretty familiar with. I know I still feel traumatized from my childhood when I got head lice at my grandma’s house and had to go through the whole ordeal.
Dr. Molly Youssef: The things to watch for on the scalp for head lice are particularly, of course, the lice organisms themselves. Those little tiny crawling bugs, but [check if you] can also see the nits, as well. Those are probably a little bit easier to see, and they look whitish to light yellow, little almost tiny beads around the hair.
And that can be evidence that there’s some eggs in the hair from the lice. I think those are the most common things that you can try to check for. Then of course the itching that might be present.
Dr. Angela Mattke: How contagious are they? I feel like as kids, I thought they were going to jump off of one person’s head and jump onto my head.
Dr. Molly Youssef: Fortunately, lice are not able to jump or fly and they actually don’t survive on our pets either. Those are all reassuring factors. Really, you need direct contact with the head of someone who’s infected to really have the lice transmitted to you. There’s still some controversy as to whether lice survive very long on objects such as hats, towels, combs, that kind of thing.
Dr. Angela Mattke: When we were a kid, they would enforce these no nit policies and the school nurse would be checking people’s hair before they could let them come back to school. I know that the AAP and all these associations have advocated pretty hard against that so the kids aren’t missing school, missing educational opportunities and opportunities to eat and other things like that where a school will provide all essential resources for children. It really puts an unnecessary burden on families and children and increases absenteeism.
Other than the annoyance of itching and having to treat lice, is it really a serious condition or could it have any serious long term consequences if not diagnosed and treated?
Dr. Molly Youssef: No, it’s not a serious condition. There’s no other long term health consequences related to it.
Dr. Angela Mattke: Do you generally recommend that families start with the over-the-counter lice treatments that are available to them? Because I know that there are prescription products available to families as well.
Dr. Molly Youssef: I typically recommend starting with over-the-counter treatment.
Dr. Angela Mattke: I would add, I know there’s some areas in the United States where there are higher rates of promethazine resistance and things like that. If you know that that’s your situation, you can always reach out to your provider and see if they feel that any of the prescription strength products are required or needed.
What parasites can actually cause itching, which we tend to always associate with head lice?
Dr. Molly Youssef: Scabies can cause some scalp itching. Scabies is interesting in that in most patients, it does not affect the scalp. It really only infects the scalp and causes itching and lesions potentially on the scalp in infants and very young children. I would really limit my thoughts on scabies of the scalp to infants and toddlers. For those age groups, we do tend to treat the scalp with the topical permethrin as well as the body. Whereas in older children and adults, we just treat the body and neck.
Dr. Angela Mattke: Is there a specific visual finding that is associated with scabies in that scalp region in young children and infants?