Guide to Scalp Psoriasis

What is Scalp psoriasis?

As the term suggests, scalp psoriasis is psoriasis involving the scalp. It is common and approximately half of all people with psoriasis have it on their scalp. The reason it deserves special mention is that it can be particularly difficult to treat and usually requires specifically formulated medicines.

Psoriasis in the scalp forms in the same way as in other parts of the body but the affect of the hair is to trap the scale and stop it being rubbed away as it is, for instance, with psoriasis on the elbow. The result is that the scale can quickly build up causing a thicker plaque which becomes more difficult to treat. This difficulty is compounded by the hair which also acts as a physical barrier obstructing the application of creams and ointments to the affected skin.

The net result can be stubborn thick scaly plaques which require specifically formulated scalp treatments.

What are the symptoms?

Scalp psoriasis causes redness and scaliness which may also involve the hairline, the forehead, behind the ears and the back of the neck. It can range from very mild with slight fine scaling to very severe crusted thick scaling covering the entire scalp which can in some cases cause hair loss during the flare, but will normally grow back.

A correct diagnosis of scalp psoriasis is essential in treating the condition as there are other skin disorders which may look similar such as seborrhoeic dermatitis. The difference being that scalp psoriasis scales appear fine with a silvery colour, whilst seborrhoeic dermatitis scales often are yellowish and greasy. One of the most frustrating symptoms is the constant shower of scale on to your collar and shoulders.

What is the treatment?

It should be mentioned that children can get scalp psoriasis too. Treatments will be much the same as used for adults.

There are many treatment options that can help scalp psoriasis and they all need to be used regularly. Treatments can be time consuming and it is important to select one that fits in with your lifestyle. On rare occasions scalp psoriasis has been known to have spontaneous remissions but can also remain on the scalp for lengthy periods of time

Psoriasis and Psoriatic Arthritis Alliance

A principal source of information on psoriasis and psoriatic arthritis.

Here is a list of topical treatments that you may find useful for scalp psoriasis:

Tar Products

Tar shampoos, gels, ointments and creams are commonly used to treat scalp psoriasis. They may be combined with other medications such as salicylic acid, to help remove scale, or coconut oil, to moisturise the skin. Tar is effective but it can stain clothing and jewellery and has a strong smell. As a result, some people dislike using it. The precise instructions for use will depend on the formulation of the product but tar products are usually massaged into the scalp, left in contact for a period of time, and then rinsed off. Clothes and bedding can be protected from staining by wearing a shower cap during the contact period.

Topical Steroids

These scalp products are usually formulated as liquids, gels, oils, foams, sprays or shampoo. They range from mild to very strong potency. They should not be used for long periods of time. Ideally, they should be used regularly for a few weeks to bring the psoriasis under control, and then gradually phased out, giving way to maintenance with a coal tar shampoo. Abrupt stopping of steroids can result in a rebound or worsening of psoriasis. It is not advisable to use steroid preparations on your face, other areas of sensitive skin such as under the breast and genitals and around the eyes, unless directed by your doctor. Most topical steroid medications are designed specifically for treating scalp psoriasis. These formulations are usually water and alcohol based which make them easier to wash out after treatment.

You can become resistant to some topical steroids used in the treatment of scalp psoriasis. If this happens consult your doctor for alternative medications. It should also be noted that it can take several months before such topical steroid medications will work again for skin that has become resistant.

Vitamin D Analogues

Vitamin D analogues are available in water and oil - based scalp formulations. They are usually applied once or twice a day and left in contact with the scalp. They do not smell or stain clothing, and are relatively easy to use. They can be used to bring the scalp psoriasis under control and maintain that control. Such medications should be confined to the scalp region only as it can irritate unaffected skin particularly the face. It may be advisable if you think you are prone to sensitivities to test a small patch before applying it to the entire scalp. Avoid contact with the eyes.

Vitamin A Derivative (topical retinoids)

These can be applied as creams or gels for the treatment of psoriasis and can be used in the treatment of scalp psoriasis too. These medications may be less irritating for the people with dry or sensitive skin. To avoid the drying out of skin too much and to reduce irritation, applying a moisturiser 30 minutes before these are used may help. These medications can be used on the face but should never be applied around the eye region and treated skin should not be covered.

Antimicrobial Treatment

If bacterial or yeast infections are present scalp psoriasis can become worse. A crusting scalp together with scaling and/or lymph nodes in the neck are swollen, this may indicate to your doctor that antimicrobial treatment will be necessary as there is infection present.

Mild scalp psoriasis can respond well to treatment with anti fungal shampoos that will help to reduce the yeast infection. Anti fungal shampoos may have to be used once or twice a week thereafter to maintain results.

Other things affecting the scalp

These can include scalp acne, infestations, fungal infections and alopecia. Make sure you get a correct diagnosis before starting any treatments. your doctor or healthcare provider will provide appropriate advice.

Ultra violet light

Successful outcome for using UV light treatments can be variable on the scalp because the hair blocks UV light from penetrating the scalp. It works best on shaved heads. Natural sunlight may also help again if your head is shaved or very thin. It is therefore not surprising that this is not a first line treatment.

Dithranol

Dithranol creams are effective in scalp psoriasis but like coal tar can be difficult to use. Dithranol is usually applied to the scaly plaques and left in contact for up to 30 minutes before being rinsed out. It needs to be applied with great care as it can irritate and cause purple staining of blonde or red hair. Dithranol can burn non affected skin. Lipid stabilised Dithranol (Micanol), if used correctly, can reduce staining. It should also be noted that dithranol will stain clothing and baths, showers and wash basins. Extra attention is needed.

Medicated Shampoos

There are many coal tar and non coal tar medicated shampoos for treating scalp psoriasis at your local chemist. For further advice ask your pharmacist who may be able to give you further guidance. You should also bear in mind that medicated shampoos are designed for the scalp not the hair so the use of a regular shampoo and conditioner after your scalp treatments will reduce the smell of any unpleasant medicated shampoo and leave your hair shiny and manageable.

Scalp psoriasis can get worse if it becomes infected with bacteria or yeasts and sometimes medicated shampoos with antifungal medicines can be useful in reducing the plaques.

The choice of which of these treatments is best for you is a personal one. It is a good idea to shop around and try different treatment options. In this way you can discover which one suits you best.

Some Useful Tips

Scalp psoriasis may progress down onto the forehead, neck and around the ears. These areas can be treated with the same products you use for your scalp only if indicated to use on such areas. Be careful about your face. Strong steroids should not be used on the face and dithranol can stain and burn facial skin. Avoid getting medication in the eyes.

A lot of product treatments will contain salicylic acid, known as a keratolytic. This ingredient aims to loosen psoriasis scales so they can be washed away more easily. This ingredient will be contained in both OTC and prescription products mostly found in shampoos and soaps. It should be noted that treatment with high concentrations of this ingredient can cause irritation and used over large areas of skin the body may absorb it leading to the weakening of hair shafts, causing them to break and leading to temporary hair loss. Hair should return to normal after stopping the treatment. Such products may be easier to apply at night and the head covered with a shower cap to avoid messiness and more convenient as they can be time consuming at the beginning of the day before going to work.

Softening and loosening thick scale makes it easier for topical medications to penetrate plaques and clear them. Soaking the scalp in warm water can help loosen scales which can then be removed using a comb. But be gentle - do not break the skin.

Round or fine tooth combs or brushes are generally used to remove psoriasis scales. Comb the scalp gently with a light circular motion holding the comb flat against the scalp. Loosen the scale gently then you can shampoo to flush the scale from the scalp and out of the hair. A hairdryer can be used to blow additional scales away from the scalp and the hair. Do not remove scales too fiercely as this can break the skin leading to infection. The Koebner response can occur to damaged psoriasis skin, this can also occur if you scratch or scrape your scalp roughly. If any treatments you use aggravate your psoriasis and scalp always consult your doctor. Care should be taken when removing the scales and applying topical medications so as to avoid the Koebner response.

Never use a shower cap or other occlusion method when using prescription scalp medications unless specified by your doctor.

Scalp Itch - As mentioned refraining from scratching and picking of psoriatic scales will reduce infection and the Koebner response. Over the counter medicated shampoos can help in alleviating itching. Please speak to your pharmacist about this.

Combination Medications - The treatment of psoriasis should be tailor made to each person. A doctor may try various combinations of medications before finding what works for you. Good communication between you and your doctor and good compliance will ensure optimum results for you. Always be aware that when medications are combined they may activate adverse reactions. By being aware of this and consulting your doctor if you are unsure will reduce the likelihood of further discomforts.

Another alternative is to soften and loosen the scales is to use oils, lotions, creams or ointments applied to a damp scalp providing they do not cause you irritation. To add to their effectiveness a hot towel placed around the head to act as an occlusion will also help loosen and soften the scales. The heating of olive oil and application to the scalp and wrapping your head in a towel for a long period of time may also help or to speed the process up applying the olive oil and then sitting under a hairdryer. Be careful not to burn the scalp with too much intensive heat.

If you are prone or suffer from dry hair conditioners and cream rinses may help to minimise and moisturise the hair and scalp. There is no evidence to suggest the use of hair dyes, hair sprays or perms will affect your scalp, however please advise your hairdresser before embarking on any treatments so that they can apply patch tests to see if any of their products will irritate your scalp or psoriasis lesions. They may be able to use gentler products. If you have the need to use head lice shampoo preparations it is unlikely you will have a reaction but they can be irritating and great care should be taken not to get the solution into open cuts or lesions or extensively scratched skin.

Hair Matters

It can be highly embarrassing for you finding or going to a new hairdresser or barber. If they are reputable and understanding they should have a knowledge of conditions such as scalp psoriasis and therefore will be able to best advise you on styles, colourings and hair products. It is always worth making general enquiries of friends and relatives about local hairdressers or contacting the Hairdressers' Council for further advice that may be useful. Some hairdressers are also happy to visit your home if you would prefer not to go to a salon.

When applying scalp products part the hair and hold it in place while you drip the oil or lotion directly onto your scalp. Repeat this process until the whole of the affected area has been treated. Conditioners and cream rinses to help combat dry hair can be used after you have completed using your medication. Hair dyes and sprays do not usually irritate the scalp in scalp psoriasis. However, it may be sensible to test a cosmetic product on a small area of your scalp before committing to it.

This information has been prepared by the Psoriasis and Psoriatic Arthritis Alliance and should not be used as a replacement for advice from your healthcare professionals. Always consult a doctor too. Bear in mind however, that the treatments used should never be worse than the psoriasis itself. If this is the case consult your doctor for further advice or alternative treatment options.

It is also important to realise that good patient compliance and experimentation to find an effective treatment plan which may include treatments such as topical medications and ultra violet UV light can often be combined and rotated depending on psoriasis resistance to repeated medicinal use.

With all treatments it can take at least eight weeks until you get adequate control of the plaques. Once you have achieved this it is important to maintain any improvement, and this can usually be done with regular use of a tar shampoo.

You are strongly advised to speak to your doctor or health care provider if you think you are affected by any conditions or items mentioned in this article.