a sensitive scalp is a frequent problem in daily clinical practice and often represents a major challenge for dermatologists . in particular , patients with hair loss or alopecia frequently also complain of scalp problems that must be taken into account for a successful treatment program . the main complaint of these patients relates to a sensitive scalp , for which various causes are taken into consideration : atopic disposition with tendency to sebostasis , irritation , and dermatitis ; type iv hypersensitivity to particular shampoo ingredients , such as cocamidopropyl betaine or preservatives ; age - related dryness of the skin ( senile sebostasis ) ; irritation from cosmetic hair treatments , such as changes of hair color or form ; and finally , some specific dermatological scalp conditions , such as seborrheic dermatitis , psoriasis , and their treatment sequels , especially those due to the prolonged use of topical corticosteroids . red scalp , red scalp syndrome , and diffuse red scalp disease are terms used synonymously for a condition , characterized by : persistent redness of the scalp , not explained by a specific dermatologic disease of the scalp , with or without sensation of itching or burning , refractory to topical corticosteroids and antiseborrheic agents , with aggravation in the sun , and the dermoscopic finding of teleangiectasia of the scalp [ figure 1a and b ] . in some cases , symptoms of scalp sensitivity , itching , burning , and tension , are due to the drying out and irritating effect of alcohol - based topicals , and the propylene glycol contained as a solvent in these preparations . in others , the condition evolves in the vertex area , where the scalp is maximally exposed to ultraviolet radiation ( uvr ) and is the considered as a chronic uvr - related condition with analogies to rosacea . at the same time , there is increasing evidence that uvr exposure also exerts a negative effect on hair growth and alopecia , presumably by generating reactive oxygen species while hair papilla fibroblasts of the balding scalp have been shown to have an increased sensitivity of to oxidative stress . ( a and b ) red scalp syndrome , before and after 6 months treatment with a hamamelis - containing shampoo ( erol energy shampoo ) finally , scalp burn - out has been a term most recently coined for the condition of scalp sensitivity that seems not to tolerate any external stimuli anymore . in general , the burn - out syndrome is defined as a condition of emotional exhaustion with reduced capacity that is understood to represent a development line starting with enthusiastic idealism and leading through frustrating experiences to disillusionment , psychosomatic disorders , depression , and aggression . just as the syndrome is not recognized to represent a true medical condition by the scientific community , but is rather defined as a coping problem in icd-10 , individuals are encountered in daily clinical practice with an analogous patient 's career about the condition of their scalp , which represents rather a question of problem - solving than a specific dermatologic condition . management of these conditions begins with protection of the scalp from further noxious environmental , medical , or cosmetic exposures , and acting toward its appeasement and restoration , while regaining the confidence of the patient . the first step consists in adapting the frequency of hair - washing to the condition of the scalp and hair . persons with greasy hair ( seborrhea ) should shampoo their hair often , sometimes even daily , whereas persons with dry hair ( sebostasis ) less often . a mild shampoo must be selected , avoiding ingredients with high irritation potential , or containing frequent contact allergens , such as cocamidopropyl betaine and parabens . of particular interest are herbal special care ingredients with an anti - irritant activity from traditional phytomedicine , such as chamomile ( marticaria chamomilla ) , heart seed ( cardiospermum halicacabum ) , peony ( paeonia lactiflora ) , and the virginian witch hazel ( hamamelis virginiana ) . when europeans originally encountered native americans , the american indian tribes dwelling in the northeastern regions utilized about 275 plants for medicinal purposes . the native northamerican virginian witch hazel h. virginiana [ figure 2 ] was among the most important of those plants and was used for treatment of superficial skin wounds and inflammatory skin conditions . the native americans produced witch hazel extract by boiling the stems of the shrub and producing a decoction , which was used to treat inflammatory conditions . early puritan settlers in new england adopted this remedy from the natives . a missionary , dr . charles hawes , eventually learned of the preparation 's therapeutic properties and further determined that the product of the plant 's twigs was even more efficacious . , who is credited with starting the commercial production of witch hazel extract in 1866 and establishing its wide use . from the middle of the 19 century the leaves ( hamamelidis folium ) as well as the bark ( hamamelidis cortex ) of the plant are used . the main constituents of the extract include : tannin , gallic acid , catechins , proanthocyanins , flavonoids ( kaempferol , quercetin ) , essential oils ( carvacrol , eugenol , hexenol ) , choline , and saponins . it is a strong anti - oxidant and astringent , which makes it useful as a natural remedy also for acne , psoriasis , eczema , aftershave applications , ingrown nails , cracked or blistered skin , and for treating insect bites . hamamelis twig ( usable parts of the plant : bark and leaves ) quality plays an important role . commonly used hamamelis distillate ( hmm - water ) elicits only low peaks for the active - principles . to achieve a rapid regeneration of the scalp and a positive course of the entire therapeutic process , the use of high - grade active principles from hamamelis obtained from wild stocks and sustainable production , is , therefore , essential . today , the following commercially used medicinal preparations are obtained from hamamelis , with the corresponding ingredients and applications , as listed in the table : erol energy hair care products,(apomedica , switzerland ) , based on virginian witch hazel , with the botanical name h. virginiana , have been specially developed for the care and treatment of the sensitive scalp . the shampoo is composed of extracts of h. virginiana and a shampoo base of mild tensidic character , free of cocamidopropyl betaine and parabens . originally , an observational study was carried out at the department of dermatology , university hospital of zurich , over a period of 6 months , from october 2009 to march 2010 , during which the hamamelis - products erol energy shampoo and tonic were dispensed to patients complaining of scalp irritation , with or without clinical signs of inflammation . many patients had previously used various medicinal shampoos , mainly against seborrhea and dandruff , as well as topical corticosteroids without success . after a period of application of 4 weeks , the majority of patients reported an improvement of subjective manifestations of irritation , and rated the tolerance of both products as good to excellent . the main active principles are the flavonoids and tannins , as a natural source of antioxidants . furthermore , the additional herbals contained in erol energy hair tonic promote skin metabolism and blood flow ( rosemary , field horsetail ) , act inhibitory on the proliferation of propionibacterium ( rosemary ) , have anti - dandruff activity ( rosemary ) , strengthen the connective tissue ( field horsetail ) , and stimulate healthy hair growth ( birch , stinging nettle ) . since then , in the period between august 2010 and december 2013 , erol energy shampoo has been applied successfully in 1,373 patients ( 1,233 women and 140 men ) at the center for dermatology and hair diseases professor treb to treat irritable scalp conditions or as concomitant treatment to minoxidil therapy for androgenetic alocepia . during this period , 369 ( 26.9% ) experience shows that 2% and 5% topical minoxidil in an alcohol base for treatment of androgenetic often leads to irritation of the scalp , which can have a negative impact on the patience compliance . the complaints of patients and the redness of the scalp are often misinterpreted as seborrheic dermatitis and treated with anti - dandruff shampoos and alcohol - based topical corticosteroids ( scalp applications ) , that only aggravate the problem through additional irritation . in shampoo form , witch hazel is particularly useful in the treatment of the red scalp syndrome and in preventing or soothing scalp irritation resulting from sustained use of ethanolic topical minoxidil solutions . the choice of appropriate hair - care products represents an important aspect in the management of the sensitive scalp and related conditions , such as the red scalp syndrome , and scalp burn - out . it should additionally be adapted to the specific requirements of different hair types , to age , washing habits , and most importantly , it should elicit a positive effect on problematic scalp conditions . with the erol energy hair - care products , the advantages of h. virginiana are available for successful treatment of the scalp , especially in the context of the problems associated with red scalp , scalp burn - out , and the use of topical minoxidil for androgenetic alopecia .