Scalp Dysesthesia: What Topical Treatments Can I use?
What are helpful treatments for scalp pain?
I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to scalp pain and topical treatments that can address pain.
Question
I have periodic scalp pain. I have been told it is all due to a scalp nerve problem (scalp dysesthesia). I have had several scalp biopsies to rule out all the worrisome stuff and they always come back normal. I am told I don’t have lupus. I don’t have scarring alopecia. Despite so many negative tests, I still have a lot of scalp discomfort and pain - but it comes and goes and is not present constantly. My scalp looks pretty normal - but there are times where it really is uncomfortable. I have fibromyalgia but can’t tolerate many of the medications I have tried like amitriptyline.
What topical treatments can I use for scalp pain from a scalp dysesethesia? I do not want to use pills that were recommended to me by my dermatologist such as oral gabapentin and oral pregabalin.
Answer
This is a really great question. There are many things to try. It’s a bit of a trial and error process unfortunately so it can take time to get to the right answer. You’re right that oral gabapentin, oral pregabalin are options and so are oral amitriptyline, low dose naltrexone.
But let’s shift our attention to topical treatments as per your queston.
You and your dermatologist can discuss a variety of topical treatments if oral treatments are something you do not want to consider
1) Apple cider vinegar rinses (4 parts water: 1 part ACV)
ACV rinses are easy to do. One fills up a spray bottle with 4 parts water to 1 part ACV and then sprays the scalp generously in the shower and leaves the ACV mixture on the scalp for 5-10 minutes. It can then be rinsed off.
2) Topical ketamine/amitriptyline/lidocaine (TKAL)
I really like topical TKAL for challenging cases of dysesthesia whereby patients don’t want to use oral medications. TKAL is short for topical ketamine, amitriptyline and lidocaine. We have reviewed topical TKAL in prior posts. This must be made by a compounding pharmacy. It’s not FDA approved but rather used as an option off label.
3) Topical 6% gabapentin
This can block pain. We’ve reviewed this option before (see link). Oral gabapentin is helping in dysesthesias but some patients prefer to try to go with topical agents. Topical gabapentin has helped many patients. Again, this must be made by a compounding pharmacy. It’s not FDA approved but rather used as an option off label.
4) Periodic Use of Topical Steroids
Most patients with dysesthesia do not find that topical steroids helps. In fact, that’s part of the definition. However, there can sometimes be some components of a dysesthesia that are helped by topical steroids. It could be that some patients have a completely different second condition and by reducing the activity of that condition, we can help the main dyesthesia. I will often recommend small amounts of betamethasone lotion if it helps or periodic use of Clobex shampoo once every 2-3 weeks. This can help some patients.
5) Periodic Use of Antidandruff shampoos
Similar to steroids, most patients with dysesthesia do not find that dandruff shampoos help. In fact, that’s part of the definition. However, there can sometimes be some components of a dysesthesia that are helped by limiting Malassezia yeast on the scalp. It could be that some patients have a mild seborrheic dermatitis in addition to their dysesethesia and by reducing the activity of the seborrheic dermatitis, we can help the main dyesthesia. I will often recommend use of a dandruff shampoo every 7-10 days.
6) Topical 1 % cetirizine
Topical cetirizine has best been studied for androgenetic alopecia and chemotherapy related hair loss. But sometimes I will prescribe for patients with a dysesthesia. The hope is that by affecting histamine pathways, we can help the patient’s pain. This must be made by a compounding pharmacy. It’s not FDA approved but rather used as an option off label.
7) Topical 5% Amitriptyline
I tend to prescribe topical TKAL over topical amitriptyline. However, topical amitriptyline is also an option to reduce pain.
Amitriptyline is a tricyclic antidepressant that is widely used to treat chronic neuropathic pain (pain due to nerve damage). It is recommended as a first line treatment in many guidelines.
This must be made by a compounding pharmacy. It’s not FDA approved but rather used as an option off label.
8 ) Low Level Laser Therapy
Low level laser devices sometimes help our patients with dysesthesias. Some patients find the slight warmth actually makes them feel worse. So, it’s not a guarantee. But for the most part it’s a pretty safe option and some patients find it helps. Use of a laser device a few times per week can bring relief to some.
9) Camphor-Menthol 0.5 %-0.5 % Lotion
Camphor and menthol are often mixed together to bring soothing and cooling relief. Menthol has analgesic effects on acute and inflammatory pain primarily by activating cold-sensitive TRPM8 receptors in the skin. Camphor also can block pain.
Applied topically, menthol and camphor initially induce their TRP receptors to release inflammatory mediators that include calcitonin gene-related peptide (CGRP) and substance P, which is a neuropeptide that modulates the transmission of pain signals to the CNS.
10) Capsaicin (0.075 %)
Capsaicin can help in nerve pain.
Capsaicin is a neurotoxin that acts to deplete sensory nerves of their substance P content and thereby interfere with certain sensory functions
11) Hypoallergenic Bland shampoos.
Some of our patients find a switch to hypoallergenic shampoos really helps. This can be a helpful step even when there is no clear evidence of irritant or allergic contact dermatitis. Several hypoallergenic shampoos are on the market that are devoid of fragrance, preservatives. We have reviewed these in the past
12. Witch Hazel
Several herbal ingredients are proposed to have an anti-irritant tendency and can be helpful in scalp pain syndromes. These include chamomile (Marticaria chamomilla), heart seed (Cardiospermum halicacabum), peony (Paeonia lactiflora), and the virginian witch hazel (Hamamelis virginiana). Witch hazel in particular has received great attention. We generally recommend application of pure witch hazel with a cotton ball for periods of 5-10 minutes before rinsing off. Many patients find relief from these agents.
13) Meditation/ Relaxation Exercises/Mindfulness
There is little doubt that meditation and mindfulness exercises as well as breathing exercises and tai chi and QiGong help many of our patients with more challenging nerve issues. Training in these disciplines are widely available online as well as in some communities.
14) Neck Massage and Scalp Exercises
A variety of scalp exercises are helpful for some patients.
15) Doing Less
Finally, an important principle for patients is to often do less. Less brushing of hair. Less heat. Less styling, Less tight tying of hair back. Less use chemicals. Doing less often helps a great deal for patients with dysesthesias.
Conclusion
Thanks for the great question. There are many topical options and non systemic (non-pill) options. It’s a bit of a trial and error and step by step process to determine what helps, but many many patients find one or more of these 15 things are helpful. Sometimes they are life changing! I really hope this helps you !