Disease: Scalp Psoriasis (Psoriasis of the Scalp)

    What is scalp psoriasis?

    Psoriasis is an inflammatory disease of the skin that is estimated to affect about 2.2% of the adult population. Some people may have a genetic predisposition to psoriasis. The genes affected seem to be involved with control of the immune system. Psoriasis appears as red scaling, slightly raised areas (papules) that combine to form plaques. Psoriasis classically appears on the elbows and knees, but it can affect any part of the skin. The scalp is also characteristically affected in many people with psoriasis. Like psoriasis anywhere, scalp plaques produce excess scale and can itch. Severe disease can cause a loss of scalp hair, which usually will return if the disease can be controlled.

    Picture of scalp psoriasis. Source: iStock.com.

    What is the cause of scalp psoriasis?

    It is generally accepted that scalp psoriasis, like all psoriasis, is related to genetic defects that affect certain parts of the immune system. There are undoubtedly environmental factors that trigger its initial development in genetically predisposed individuals. The belief that "emotional stress" plays a causal role or at least exacerbates psoriasis has been difficult to prove. There is no question, however, that psoriasis of the scalp can be an extremely stressful experience.

    What are scalp psoriasis symptoms and signs?

    As mentioned above, psoriasis appears as a small bump, a papule, surmounted by scale. When these papules combine, a plaque is formed that is covered by excessive layers of horny skin that is perceived as a silvery scale. This scale is shed and appears as dandruff. The scale and its shedding can be quite profuse and unsightly. Scratching these plaques, either because of itching or because of the impulse to remove it, is a very poor idea because of what is called the Koebner phenomenon (also known as the Koebner response or isomorphic response). This is a peculiar predisposition of psoriasis to develop in areas of trauma. Scratching off the scale will only make things worse. Occasionally, seborrheic dermatitis of the scalp can be confused with psoriasis since both can produce excess scale and can itch.

    How is scalp psoriasis diagnosed?

    The fact that the scalp is a hair-bearing area in most people produces challenges in diagnosis as well as treatment. If scaling plaques are present on portions of the body in a distribution characteristic of psoriasis, then the diagnosis of the scalp disease is much easier to make.

    What are topical treatments and home remedies for scalp psoriasis?

    The most important consideration in treating scalp psoriasis is getting an effective medication into the skin. Both the hair and any scale covering the disease act as an impediment to treatment. Removal of the scale in a nontraumatic fashion is very important. This can be accomplished by shampooing frequently. Using tar, selenium, or salicylic acid-containing shampoos can be helpful. This may have to be done at least twice a day initially if the scale is sufficiently thick. Gently rubbing off the scale with the fingertips and not the nails is important.

    It should be appreciated that scaling is not due to dryness but to the excessive production of the horny layer of the skin. Occasionally, it may be necessary to cover the scalp overnight with mineral oil. To avoid an unpleasant mess, it is necessary to cover the scalp with a shower cap or swim cap. With moderate or severe scalp disease, the addition of a topical steroid is often required. The potency of the steroid would depend on the severity of the condition. The type of vehicle (lotion, solution, or foam) depends on physician and patient preference. It is important to remember that the medication must get past the hair in order to reach the scalp skin. Sometimes other medications may be of benefit, such as topical calcipotriene (Dovonex, Sorilux) in a lotion or foam form.

    Learn more about: Sorilux

    What are office treatments for scalp psoriasis?

    Rarely, it may be of benefit to inject triamcinolone acetonide directly into psoriatic plaques. Aside from the pain involved, the benefit only lasts about six weeks at best. Ultraviolet light in wavelengths near 313 nm (narrow band UVB) is effective in psoriasis. The hair, however, can pose a barrier to effective administration unless it is removed or sparse. The excimer laser puts out laser light in these UV wavelengths also and can be of benefit if the amount of scalp involvement is limited.

    What are systemic treatments for psoriasis?

    If the scalp is involved as part of severe psoriasis deemed too extensive to be treated practically with topical medications, then medications delivered orally or through the skin may be necessary. All these medications comprise more risk when compared to topical medication. They include oral drugs like methotrexate (Rheumatrex, Trexall), cyclosporine (Sandimmune), acitretin (Soriatane), apremilast (Otezla), and some of the so-called biological drugs that are administered by infusion into a vein (infliximab [Remicade]) or by injection into the deeper layers of the skin like etanercept (Enbrel), adalimumab (Humira), ustekinumab (Stelara), and secukinumab (Cosentyx). Regular laboratory work is required to monitor for the toxicities associated with these systemic therapies.

    Learn more about: Rheumatrex | Trexall | Sandimmune | Soriatane | Otezla | Remicade | Enbrel | Humira | Stelara | Cosentyx

    How is scalp psoriasis diagnosed?

    The fact that the scalp is a hair-bearing area in most people produces challenges in diagnosis as well as treatment. If scaling plaques are present on portions of the body in a distribution characteristic of psoriasis, then the diagnosis of the scalp disease is much easier to make.

    What are topical treatments and home remedies for scalp psoriasis?

    The most important consideration in treating scalp psoriasis is getting an effective medication into the skin. Both the hair and any scale covering the disease act as an impediment to treatment. Removal of the scale in a nontraumatic fashion is very important. This can be accomplished by shampooing frequently. Using tar, selenium, or salicylic acid-containing shampoos can be helpful. This may have to be done at least twice a day initially if the scale is sufficiently thick. Gently rubbing off the scale with the fingertips and not the nails is important.

    It should be appreciated that scaling is not due to dryness but to the excessive production of the horny layer of the skin. Occasionally, it may be necessary to cover the scalp overnight with mineral oil. To avoid an unpleasant mess, it is necessary to cover the scalp with a shower cap or swim cap. With moderate or severe scalp disease, the addition of a topical steroid is often required. The potency of the steroid would depend on the severity of the condition. The type of vehicle (lotion, solution, or foam) depends on physician and patient preference. It is important to remember that the medication must get past the hair in order to reach the scalp skin. Sometimes other medications may be of benefit, such as topical calcipotriene (Dovonex, Sorilux) in a lotion or foam form.

    Learn more about: Sorilux

    What are office treatments for scalp psoriasis?

    Rarely, it may be of benefit to inject triamcinolone acetonide directly into psoriatic plaques. Aside from the pain involved, the benefit only lasts about six weeks at best. Ultraviolet light in wavelengths near 313 nm (narrow band UVB) is effective in psoriasis. The hair, however, can pose a barrier to effective administration unless it is removed or sparse. The excimer laser puts out laser light in these UV wavelengths also and can be of benefit if the amount of scalp involvement is limited.

    What are systemic treatments for psoriasis?

    If the scalp is involved as part of severe psoriasis deemed too extensive to be treated practically with topical medications, then medications delivered orally or through the skin may be necessary. All these medications comprise more risk when compared to topical medication. They include oral drugs like methotrexate (Rheumatrex, Trexall), cyclosporine (Sandimmune), acitretin (Soriatane), apremilast (Otezla), and some of the so-called biological drugs that are administered by infusion into a vein (infliximab [Remicade]) or by injection into the deeper layers of the skin like etanercept (Enbrel), adalimumab (Humira), ustekinumab (Stelara), and secukinumab (Cosentyx). Regular laboratory work is required to monitor for the toxicities associated with these systemic therapies.

    Learn more about: Rheumatrex | Trexall | Sandimmune | Soriatane | Otezla | Remicade | Enbrel | Humira | Stelara | Cosentyx

    Source: http://www.rxlist.com

    The most important consideration in treating scalp psoriasis is getting an effective medication into the skin. Both the hair and any scale covering the disease act as an impediment to treatment. Removal of the scale in a nontraumatic fashion is very important. This can be accomplished by shampooing frequently. Using tar, selenium, or salicylic acid-containing shampoos can be helpful. This may have to be done at least twice a day initially if the scale is sufficiently thick. Gently rubbing off the scale with the fingertips and not the nails is important.

    It should be appreciated that scaling is not due to dryness but to the excessive production of the horny layer of the skin. Occasionally, it may be necessary to cover the scalp overnight with mineral oil. To avoid an unpleasant mess, it is necessary to cover the scalp with a shower cap or swim cap. With moderate or severe scalp disease, the addition of a topical steroid is often required. The potency of the steroid would depend on the severity of the condition. The type of vehicle (lotion, solution, or foam) depends on physician and patient preference. It is important to remember that the medication must get past the hair in order to reach the scalp skin. Sometimes other medications may be of benefit, such as topical calcipotriene (Dovonex, Sorilux) in a lotion or foam form.

    Source: http://www.rxlist.com

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