Why is my scalp so tender?

Considerations when the scalp feels bruised and tender

There are many reasons why a scalp can feel tender or bruised. One needs a careful evaluation by a dermatologist if this symptom persists. Below the common causes of a tender scalp are reviewed. This list is by no means exhaustive but provides a useful overview.

1) Seborrheic dermatitis.

Seborrheic dermatitis (SD) is an inflammatory condition of the scalp that affects up to 5 % -10 % of adults. Males are more commonly affected than females. SD occurs on body sites where the skin is oily such as the scalp, eyebrows, sides of nose, eyelids and chest. Individuals with SD of the scalp develop red, flaky skin that is often itchy. It’s not uncommon for the scalp to be tender as well. Tenderness is SD frequently becomes more of an issue the longer and longer it has been since the individual last shampooed their hair. The scales in SD can be yellow, white or grey colored and are often described as being "greasy." This differs from scalp psoriasis where the scales are often silver and powdery (see below). 

2) Psoriasis

Psoriasis is complex immunological disease which can affect not only the skin, but also affects the nails and joints. Scalp psoriasis occurs in about 50 % of patients with skin psoriasis and is very often the first site involved. Patients have scalp redness, flaking and scaling. Patients may also have bothersome itching and not uncommonly the scalp is tender. Tenderness in scalp psoriasis may accompany areas of scalp bleeding. Although the redness and flaking often cause embarrassment, scalp psoriasis does not usually cause hair loss. 

3) Scarring alopecias

Scalp tenderness may be a sign of scarring alopecia. Scarring hair loss conditions or "cicatricial alopecias” are a group of hair loss conditions which lead to permanent hair loss. These conditions may frequently be associated with redness of the scalp as well as scalp itching, burning and/or pain. Tenderness and a bruise-like feeling are not uncommon. These feelings may not be present all the time but rather may come and go. Occasionally it may even hurt to move the hair or the patient may feel as though their hair has been kept in a tight ponytail despite wearing it down. The scarring alopecias include conditions with names such as lichen planopilaris, folliculitis decalvans, lupus and several others. 

4) Other inflammatory diseases

A wide variety of other inflammatory scalp conditions, including dermatomyositis, morphea, scleroderma and scalp rosacea can be associated with scalp redness. A scalp biopsy can help differentiate these entities.

5) "Red Scalp Syndrome"

'Red scalp syndrome" is a condition which occurs in individuals who have persistent scalp redness that is not explainable by any other condition. The condition was first described by Drs Thestrup and Hjorth Patients with the Red Scalp Syndrome may have itching and burning but typically do not have scaling or flaking. Occasionally tenderness can be a predominant feature.

6) Irritation

Many products that are applied to the scalp or hair can cause irritation. This is often due to an irritant contact dermatitis that the product elicits. Such products include many cosmetic products, including gel, mousse, hair spray and hair dyes. Some treatments for hair loss can also be associated with irritation, itching and tenderness, including minoxidil and other topical products containing irritants such propylene glycol.

7) Allergy

Shampoos, hair dyes and even some cosmetic products can cause allergic reactions in the scalp. Although some individuals with allergy have itching in the scalp, many have only slight tenderness. In such cases, a rash may be present on the neck, ears or back where the product came into contact with the skin. The five most common allergens in shampoos include fragrance, cocamidopropyl betaine, MCI/MI, formaldehyde releasers and propylene glycol.

8) Infection

Infections are a possible causes of a tender scalp. Bacterial, viral and fungal infections may cause redness and pain in the scalp. Determining the specific cause may come from a careful history and scalp examination and sometimes submission of a swab or piece of scalp tissue to the microbiology laboratory. 

Bacteria, such as staphylococci, may cause infections of the scalp. Bacteria may also cause infection of the hair follicle, which is a condition called " bacterial folliculitis." A variety of viral infections cause scalp redness and pain. Chicken pox and shingles are two such examples. Scalp ringworm or “tinea capitis” refers to infection of the scalp by certain types of fungi. Scalp redness, tenderness and scaling may be seen in these cases.

9) Alopecia areata

Alopecia areata is an autoimmune condition affecting about 2 % of the population. It is not typically a cause of scalp tenderness. However, scalp tenderness is occasionally reported by patients. A specific form of alopecia areata known as cephalagic alopecia areata is associated with pain. It is hypothesized that factors secreted from nerves play a role in the pain.

10) Scalp Injury and Trauma

Patients with scalp injuries, either due to previous accidents or surgeries, may have persistent scalp tenderness. Burns from fire, chemicals or radiation can cause temporary or persistent tenderness in the scalp. 

11) Sun damage

Patients with extensive sun damage, from years of sun expose, may frequently have scalp tenderness.

12) Cancers

A variety of pre cancers and cancers of the skin, including non melanoma and melanoma skin cancers, can cause tenderness in localized areas of the scalp. A biopsy may be obtained to reach the precise diagnosis.

13) Headaches

Headaches, especially tension headaches, can be a cause of scalp pain and tenderness. For some individuals, stress, anxiety and depression can cause or worsen the tenderness on account of making muscles tense.

14) Temporal arteritis

Temporal arteritis is a potentially worrisome cause of scalp pain amd tenderness. Temporal arteritis is a condition in which the temporal artery becomes inflamed and quite tender to touch. Patients with temporal arteritis may develop jaw pain, headaches, and visual disturbances. Most affected individuals are older adults. 

Conclusion

There are many causes of scalp tenderness. Fortunately, the cause of the tenderness can usually be diagnosed from a thorough examination of the scalp. In complex or challenging situations, a scalp biopsy should be performed to confirm the diagnosis.