Psoriasis that occurs on the scalp is called scalp psoriasis. It can present as a single patch or as several patches. It can even involve the entire scalp. It can spread beyond the hairline on the face in the front, behind the ears, and on the neck.
The American Academy of Dermatology (AAD) tells us that about half the people with plaque psoriasis experience at least one flare-up of scalp psoriasis.
This condition of the scalp can be mild or severe. Mild psoriasis of the scalp presents with fine scales, which look like dandruff. At times, it may be so mild as to go unnoticed.
In the severe condition, there are thick and adherent crusted scales that cover the entire scalp. It can last a long time with associated intense itching that can interfere with your sleep. Severe scratching leads to scalp infections and hair loss.
Causes of Scalp Psoriasis
Scalp Psoriasis is characterized by skin cells of the scalp multiplying ten times faster than normal. The cells move from the lower layer of the epidermis of the skin (where they are formed) to the upper layer of the epidermis.
The uppermost layer of the epidermis consists of dead skin cells. This migration of skin cells normally takes 4 to 6 weeks. In psoriasis, this period is reduced to only 2 weeks.
As a result of this fast multiplication and fast migration of the skin cells, there is an accumulation of dead cells on the outermost surface of the skin. This excessive volume of dead skin cells on the outermost layer of the epidermis causes the silver or whitish flakes of psoriasis on the scalp.
Certain factors can trigger the onset of a recurrence. They are stress, smoking, alcohol, severe sunburn, cold and dry weather, injury to the scalp, and certain medicines.
Symptoms of scalp psoriasis
Psoriasis of the scalp can present as a single patch, multiple patches or it can be present on the entire scalp. The skin of the scalp becomes red, scaly and it itches. The following symptoms tell you how scalp psoriasis may present. Not all the symptoms may be present in all cases. The symptoms are very similar to those of skin psoriasis.
- Red raised patches of skin covered with silvery-white scales
- Depending on the severity, scalp psoriasis may not be noticeable or the lesions may be inflamed and swollen.
- The scalp is dry.
- There is itching and soreness.
- The white scales look like dandruff and slough off on the shoulders giving an impression of a severe dandruff condition.
- A burning sensation of the scalp may be present.
- Scalp psoriasis may be accompanied by psoriasis on the elbows, knees, hands, and feet. Nail involvement may also be seen.
- Hair loss is not an effect of scalp psoriasis but it is the excessive scratching or removal of the scales that cause hair loss. There may be some amount of thinning of hair in the severe form but the hair grows back after the flare-up has subsided.
- Psoriasis of the scalp has periods of remissions alternating with flaring up of the condition.
Impact of Scalp Psoriasis
The most distressing thing for a person with scalp psoriasis is the falling of the silvery-white scales on the clothes. This can give an impression to others of severe dandruff. Though dandruff is not an infection and is nothing but dead skin cells of the scalp, people do look upon it with disdain.
The problem is that there is no cure for scalp psoriasis and such a person has to perpetually face this problem except when there is remission. Wearing of dark-colored clothes highlights this problem even more. This causes emotional distress and anxiety to the person suffering from this condition.
The health complications of scalp psoriasis are similar to those developed in a person with its skin version. They include skin cancer, renal and heart complications, and more. You should about these complications.
Treatment and management guidelines
There is no cure for psoriasis of any kind. At times, scalp psoriasis, especially the mild type, may go into remission on its own. However, most of the time you require treatment to control the symptoms of itching and burning and give relief to the patient.
Mild scalp psoriasis usually requires only topical applications to control the symptoms.
Tips to control itching of the scalp
- Shower with cold water.
- Do not use a hot air hair drier to dry your hair.
- After shampooing your hair, use a hair conditioner. Best shampoos to control itching are those, which contain menthol, or topical steroids, or antihistamines.
Factors that influence treatment
Treatment options for scalp psoriasis differ from person to person and depend on the following factors.
- The severity of the disease
- How the disease responds to a particular line of treatment that is in force. If a particular treatment does not give results, it may be necessary to combine it with another therapy or change the medicine itself.
- Whether there is accompanying psoriasis elsewhere on the body.
- Amount of hair loss
The medications used for treating skin psoriasis are the same as those for scalp psoriasis. However, instead of creams, ointments, and lotions used in treating skin psoriasis, you use shampoos, foams, or oils to treat scalp psoriasis.
In order that the topical medications applied penetrate the skin, it is necessary first to remove the scalp psoriasis scales. For that, it is necessary to soften the scales first.
Tips to apply shampoos, foams, or oils on the scalp
- Apply gels on the scalp, which contain keratolytic agents such as salicylic acid, urea, lactic acid, or phenol. These agents act as good scale softeners. This has to be done by parting the hair and gently rubbing it on to the affected area. Keep it for a few minutes. Over the counter products contain 1% to 3% salicylic acid and should be used. Higher concentration can irritate the skin. Salicylic acid can weaken the hair shaft causing it to break. Hair returns back to normal after stopping the treatment.
- Gently comb your hair with a soft brush or a fine-toothed comb. Take care not to aggravate the scalp when combing.
- Shampoo your hair with a shampoo containing salicylic acid and rinse it.
- Apply emollients while the hair is still damp. Emollients are softeners, which soften the skin of the scalp and help to treat dry skin by preventing loss of water from the skin. They could be in the form of petroleum jelly or thick creams, lotions, or ointments. You should apply them by parting your hair and gently rubbing it onto the scalp. Apply once a day and cover the scalp preferably with a plastic shower cap for better effect.
Treatment options for mild scalp psoriasis
For mild scalp psoriasis, the following treatment options work with good effect.
Coal tar products
These are available over the counter as shampoos, gels, creams, ointments, and soaps. Coal tar reduces the itching and scales and also has anti-inflammatory action.
Rub the coal tar shampoo gently onto the scalp and leave for five minutes before rinsing it off. Leave the gels, creams, and other products onto the scalp overnight. The disadvantage lies in its odor and the staining of the clothes that it causes.
Salicylic acid shampoos and soaps are available as over the counter and prescription products. They soften the scales and facilitate their removal.
If necessary, your dermatologist will inject steroids into the scalp lesions to control the inflammation and give relief from itching and burning.
Treatment options for moderate to severe scalp psoriasis
Scalp psoriasis of moderate to a severe degree may require mild or potent topical corticosteroids. However, your dermatologist also has options for other topical treatments. You should keep them applied for some time before washing the scalp.
Anthralin or Psoriatic.
Anthralin does not contain steroids and it may take up to weeks for you to see any results. This is a time-release cream wherein the active ingredient in the cream is gradually released into the skin. You should leave it applied on the scalp for about 30 minutes before washing the scalp with cool water.
Calcipotriene or Dovonex
This belongs to a class of drugs called vitamin D3 derivatives. It is available as a cream or solution. For the scalp, it will be more convenient to apply the solution.
It acts by slowing down the excessive and fast growth of the skin cells of the scalp. Before applying the solution, comb your hair with a soft brush or a fine-toothed comb to remove any sloughed scales. Apply by parting the hair. Take care to see that the solution does come onto the face and near the eyes.
Keep the solution overnight after covering it with a plastic shower cap. Wash off in the morning. It may take 2 weeks to see any benefits and almost up to 8 weeks to see the full results.
Calcipotriene and Steroids
Calcipotriene is combined with betamethasone diproprionate (Taclonex scalp), which is a potent steroid, for topical use in more resistant cases and when more inflammation is present. You should apply it once a day for two to eight weeks.
Do not use this combination for more than 8 weeks. Take care to see that this application does not come in contact with the face or eyes.
Tazarotene or Tazorac
Tazarotene or Tazorac is a prescription topical retinoid, which is available as gel or cream. Retinoids are synthetic derivatives of vitamin A. Apply the gel at night and leave overnight. Allow it to dry before you lie down to sleep.
It reduces the inflammation of the psoriatic lesions. Avoid its contact with the eyes. The scalp should be dry before applying the gel. Apply only a thin layer. Use concentration of 0.05% to 1%.
Giving phototherapy or light therapy (UV light) to the scalp is tricky due to the hair. It is easier if you have thin hair or have shaved your scalp. Otherwise, it is necessary to part the hair in rows so that the UV rays reach the scalp.
However, UV combs are available, which are handheld devices and which deliver a higher dose of light. Natural sunlight is also good for scalp psoriasis but this will help if you have thin hair or a shaven scalp.
Moderate to severe scalp psoriasis with the presence of psoriasis lesions elsewhere on the body may require more aggressive treatment in the form of systemic medications. Antimicrobials may also be prescribed if there is infection indicated by crusting and scaling along with enlarged lymph nodes in the neck. The following psoriasis specific treatments will help:
Due to its depressive action on the T cells of the immune system, methotrexate inhibits the overproduction of the skin cells and reduces inflammation. You could read a detailed description of this systemic drug.
Retinoids are synthetic vitamin A chemical compounds, which regulate the growth of the epithelial skin cells and also affect the immune system.
Cyclosporine or Ciclosporin (as it is sometimes spelled) is an immunosuppressant drug (suppresses the immunity of the body), similar in effectiveness to Methotrexate. For details, you could read this post.
Biologics are also called immunomodulatory drugs as they act by modulating the immune system. They focus on the specific function of the immune system, which leads to auto-immune diseases such as psoriasis and rheumatoid arthritis. Details on biological drugs are given here.