Last updated: May 20, 2009
psoriasis-head-toe-guide
(VEER/HEALTH.COM)
One size does not fit all when it comes to psoriasis treatments. How you ease symptoms of this chronic disease depends in large part on where psoriasis appears on your body. “We think of the skin as one organ, but its different in different places,” says Steven Feldman, MD, PhD, professor of dermatology at the Wake Forest University School of Medicine in Winston-Salem, N.C.


“The skin of the eyelid is completely different than the skin on the palm or the sole of the foot,” Dr. Feldman says. Because the skin in these areas will absorb medications differently, you need a tailored approach.

“When dealing with the sensitive skin of the face, you dont need high potency. But when dealing with the palms or sole of the foot, you have to use the stronger stuff to get the adequate anti-inflammatory effects,” Dr. Feldman says. If your psoriasis is all over your body, systemic oral medications or biologics might be your best bet.

Heres a rundown of common areas affected by psoriasis—and what you should know about treating them.

Scalp
Treat the scalp topically with medicated liquids, mousse, shampoo, sprays, gels, tar products, and soaps made especially for this difficult area. “Scalp psoriasis can be among the most recalcitrant,” says Neil Korman, MD, PhD, clinical director of the Murdough Family Center for Psoriasis in Cleveland. “Systemic therapy—pills or shots—may be necessary if a patient does not improve with an aggressive topical regimen.” Not only is psoriasis on the scalp stubborn, but treating it “can be incredibly time consuming and difficult to do,” Dr. Feldman says. Its time consuming to get medication directly onto the scalp while avoiding the hair; tar products, while effective, can be smelly and stain light hair; and some scalp treatments must be left on overnight, which can be a messy proposition.

To make scalp treatments easier and more effective, the National Psoriasis Foundation recommends first removing any scales on the scalp so the medication can seep in more easily. Loosen them by soaking the scalp in warm water. The foundation also recommends rubbing some heated olive oil onto the scalp, wrapping your head in a towel and leaving it on for several hours, or using a hair dryer. Remove the scales carefully with a fine-tooth comb or brush before applying the treatment. If you need to leave the medicine on overnight, invest in a good, comfortable shower cap for less mess.

Its common to use these treatments for about two months; once the psoriasis has cleared you can maintain this by using a medicated shampoo several times a week. Steroid creams and injections are also used for the scalp, although ideally in moderation. Other topical medications derived from vitamin D and A are also sometimes used.


Face
According to the National Psoriasis Foundation, the most common areas for facial psoriasis to appear are the forehead, upper lip, around the eyebrows, the upper forehead, and the hairline. Dermatologists try to avoid aggressive topical steroids in these highly delicate areas because they absorb medication readily and are prone to side effects such as skin thinning. Medications can also irritate the eyes.

Dermatologists usually start with mild topical steroids or topical immunomodulators, Dr. Korman says. If the patient doesnt respond to these treatments, phototherapy or other systemic treatments might be appropriate. “If psoriasis on the face is causing major social-interaction problems, we need to be more aggressive,” Dr. Korman says.

Elbows and knees
These thick-skinned spots are ideal for topical steroids, salicylic acid, and coal tar. “In stubborn places such as the elbows and knees, I tend to use stronger topical steroid products or combinations of topical steroids and vitamin D analogues. I often tell patients to use topical medicine every day for a couple of weeks, and then taper off to once or twice a week,” says Robert E. Kalb, MD, clinical associate professor of dermatology at the University at Buffalo School of Medicine in Buffalo, N.Y.

Hands and feet
The first step in treating psoriasis on the hands and feet is to try moisturizers and mild soaps. If this doesnt work, then a vitamin D derivative such as Dovonex and/or topical steroids should be next. If the psoriasis is severe, oral medications or a biologic might be the best course of action.

Genitals and skin folds
Psoriasis appearing in less visible parts of the body, such as the perineum, armpits, under the breasts, and around the genitals and buttocks, is known as inverse psoriasis. These sensitive areas can be breeding grounds for yeast or fungal infections, so your doctor might recommend adding an antifungal and yeast cream to your regular treatment to avoid such infections. Although topical steroids can be effective in these areas, Dr. Kalb tries to avoid using them here, opting instead for vitamin D analogues or topical calcineurin inhibitors. If the psoriasis is severe, he might prescribe topical steroids for a short period of time before switching over.

Psoriasis treatment usually proceeds by trial and error. Experts recommend using mild creams and phototherapy on affected areas at first. If your psoriasis is resistant or severe, your doctor might switch to systemic solutions, which include oral medications and biologics, either alone or in conjunction with some of the above treatments. The good news is that with so many options available, you and your doctor can take the time to find one that works best for you.