Getting Ahead of Flakes in Kids, Part 1: Cradle Cap

Cradle cap aka milk crust, or honeycomb disease: looks like dried mayo, right?

It doesn’t really matter how old you are, but an itchy, flaky, or itchy-flaky scalp can be a drag. Seborrhea dermatitis is often the culprit here. What makes it interesting to skin geeks and horrifying to infant parents (eek! cradle cap!), or teens dusting hairsnow off their shoulders(Drat! dandruff!) is how it can happen throughout childhood for some, and not at all for others. Before you rush to the mirror and check your scalp, let’s scratch below the surface a bit.

Seborrhea dermatitis refers to the ‘-itis’ (inflammation) that happens to areas rich in sebum-producing oil glands on the skin, including the scalp and folds of the groin, diaper area, as well as the underarms and thighs. The cause of this rash and its many forms is unknown, but there are suspects. Naturally occurring skin yeasts (some implicate species of Malassezia , and others point fingers at Pityrosporum varieties) appear to kick off an inflammatory response with the fatty acids produced on these areas of the body, in certain hosts. GIven the right conditions–boom! Rash city.

Flares of seborrhea dermatitis can occur in response to exposure to medications, stress, and certain kinds of medication. In children, it tends to arise from fluxes in hormones, such as in the infant’s exposure to maternal hormones during childbirth, or with the onset of puberty.

Normally, skin cells all over the body are constantly shed and replaced, unnoticed and too small to be seen. In areas of ‘seb derm,’ the cycle of irritation deranges this process a bit, causing rafts of skin cells to fall off in larger pieces. When present, the cycle of itching and scratching the scalp only amplifies this process. Soon enough, there are the drifts of white flakes on a shirt or blouse. And here’s the thing: in terms of scalp flakiness, parents can see one variety of seborrhea dermatitis on the heads of infants and small children, and then a very different version during the teen years and into adulthood. From preschoolers to preteens, seb derm of the scalp generally goes on hiatus. Thus, we might consider other diagnoses when we encounter 5-10 year olds with scales and flakes in their hair.

Any way you dice it, in my humble opinion, cradle cap is pretty funky. Known as” infant seborrheic dermatitis,”  cradle cap appears as white, creamy, yellow-brown, or (gag) yellow-green greasy patches. Infant seb derm of the scalp appears on the crown of the head, and doesn’t itch, ache, or bleed. Most commonly, the babies who have it (about 1 in 10)are untroubled, but their  parents driven to distraction by it. In some babies as in older kids and adults, seborrhea dermatitis manifests elsewhere as reddish, or cream-colored patches crop up in other areas of skin folds (neck, armpits, diaper area). For the examining clinician, this combo of scalp rash and body distribution can help clinch the diagnosis.

Generally, cradle cap peaks in frequency at about at 1 to 2 months of age. It is not unusual to see it on kids through their first birthday. And, less often, it can be found in kids through preschool age. Happily, most cases are mild and do not require treatment beyond regular passing of a soft bristle hairbrush over the affected area of the scalp at bedtime. Easy enough.

For the more obstinate patches of cradle cap, parents can massage an unfragranced, neutral oil–such as mineral oil (aka ‘baby oil’) or even (yes!) olive oil–onto the scalp before bedtime or nap. You might find the babies love the head rub so much, you do it whether they have a patch of cap up there or not. After the oil has softened the patches of crud (at least 10-15 minutes), parents can gently make small circular motions with a (repurposed) soft bristle toothbrush to help it break up the patch and slough it off. Daily cleansing with baby shampoos is also appropriate and may help clear things up as well. Gentleness is key; no elbow grease here!

If the cradle cap continues to advance in spite of all these efforts, it might be a good idea to check in with the baby’s child care provider to take interventions to the next level. Recalcitrant cradle cap may require some store-bought dandruff shampoo. If you use it, leave it on for a few minutes and keep it out of  baby’s eyes!

In extreme cases, bacterial infections can take root, can make babies pretty miserable, and require an evaluation. If ever in doubt, call. Or, kindly suggest that you email a photo of the eruption in question to help the clinician assess the level of severity. That may save time and possibly a trip in to the office or clinic. Of course, if there is a concurrent body rash that is unresponsive to your best efforts at home, I recommend family’s let their primary care clinician know: there may be a (skin) app for that, too.

Next post: Flakes in Kids, part 2: Dandruff.

Link to photo above

Cartoon: pending. We are experiencing technical issues!

Jack Maypole, MD has plenty of material to work from. He is director of Pediatrics at the South End Community Health Center and he is director of the Comprehensive Care Program at Boston Medical Cent more


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