What To Do About Scalp Psoriasis: Dermatologist-recommended Treatments

Wondering about those itchy, scaly patches on your scalp and whether there's anything you can do about them? Don't fret. You might be experiencing psoriasis on your scalp, and there are ways to treat it. There is no cure for the autoimmune condition of psoriasis. But there are ways to manage inflamed skin patches.

What Is Scalp Psoriasis?

Scalp psoriasis causes inflammation on the scalp that presents as raised plaques and scales that can itch, burn, and sting. The immune system will speed up the growth of skin cells, and because they are growing too fast, the cells will pile up instead of slough off. This pile-up of skin cells forms the plaques you see on your scalp. Besides the scalp, psoriasis typically presents itself on the elbows and knees.

Why Do People Get It?

About 45-56% of people with psoriasis have scalp psoriasis. Additionally, scalp psoriasis can be found on the hairline, forehead, neck, and around the ears.

"We don't know why some people get it on the scalp, and some don't," said Adam Friedman, MD, professor of dermatology at George Washington University School of Medicine and Health Sciences.

Dr. Friedman explained that while it's not known exactly what causes plaque psoriasis, a combination of genetic makeup and environmental factors are believed to be involved.

While there isn't a known reason for why people get psoriasis on different parts of the body, Dr. Friedman said he finds that those with scalp psoriasis also get inverse psoriasis, which occurs on the folds of skin like the groin and underarms. Dr. Friedman noted that because those areas can be moist, psoriasis might look different.

"So, people who have this are often underdiagnosed because it doesn't have that classic appearance. In the groin area, it can be assumed it's a yeast infection or sexually transmitted disease. This is why it's important to make a correct diagnosis," Dr. Friedman said.

Robert T. Brodell, MD, chair of the department of dermatology at the University of Mississippi Medical Center, added that many of his patients with scalp psoriasis also have it on their elbows and knees, as well as experience pitting in their fingernails.

"I do also have patients with it only on the elbows or only the knees or only on the scalp. So, it's a mixed bag," Dr. Brodell said.

Symptoms

Symptoms of psoriasis on the scalp might include:

• Thick, crusted plaques on the scalp
• May appear powdery with a silver sheen
• Scaling that covers parts of the scalp or the entire scalp
• Scaling that may extend beyond the hairline onto the neck

"It can be itchy and painful, and all that together can make psoriasis that affects a small body area disabling," said Dr. Friedman.

Scalp psoriasis can have a social impact, too, Dr. Friedman added. "If someone sees a person with a flaky, red scalp, they may assume the person is unkempt or has a fungal infection, so there is an added level of anxiety associated with that in terms of misunderstanding what scalp psoriasis is and punishing the patients," Dr. Friedman said.

How Does Psoriasis Affect the Scalp and the Hair?

Psoriasis on the scalp can sometimes cause hair loss. "Even a little inflammation can cause hair loss," Dr. Friedman pointed out. "Hair is very fickle, it's a prima donna, so to speak; it wants a perfect environment to grow." Hair is so fickle, Dr. Friedman noted, that even dandruff can cause hair loss.

Hair often grows back once psoriasis clears on the scalp, but there are ways to help prevent further hair loss:

• Gently comb and brush away the scales
• Avoid picking off the scales
• Allow your hair to air dry
• Keep your fingernails short to prevent scratching your scalp
• Use conditioner after you shampoo
• Use medicated shampoo and alternate with normal shampoo

Treatment

There are several options for treating scalp psoriasis, and your dermatologist may use one or a combination of the following to find what works best for you.

Topical Ointments

First-line therapy for plaque psoriasis on any part of the body is a topical anti-inflammatory, Dr. Friedman said. Topical treatments include:

• Medicated shampoos
• Steroids
• Tars
• Prescription topicals

"The tricky part is that using an ointment or cream on the scalp can be difficult; think about applying an ointment or cream in a hairy area, that's not easy," Dr. Friedman said.

In some cases, Dr. Friedman said, foam, liquids, or gels are better options for the scalp. However, he adds that some of his patients who have brittle or dry hair like using ointment on the scalp.

Some topical options are available over the counter (OTC). When looking for a treatment, there are specific ingredients you should look for. Salicylic acid is an ingredient that softens plaques and scales and removes them from the skin. Tar (made from coal or wood) is an ingredient that slows skin cell growth and reduces inflammation, itching, and scaling.

Before buying OTC products, you should look for a Seal of Recognition. This program includes products that aim to be non-irritating and safe for people with psoriasis.

Phototherapy

Phototherapy shines ultraviolet (UV) rays on the skin with the intention of slowing skin-cell growth. It can also suppress an overactive immune system, reduce inflammation, and relieve itchiness so the skin can heal.

A dermatologist may use a handheld device, which looks much like a blow dryer, to treat scalp psoriasis.

The downside of phototherapy? "While it works well, some patients find it hard to go into an office three times a week for light therapy," Dr. Friedman said.

Systemic Therapies

If topicals or UV light therapy do not help your scalp psoriasis, your doctor may prescribe oral medicines or biologics.

There are several types of oral medications that doctors may prescribe to improve psoriasis symptoms. These drugs work by slowing down the immune system. Some examples include:

• Methotrexate
• Apremilast (Otezla)
• Tofacitinib (Xeljanz)
• Cyclosporine
• Acitretin (Soriatane)

Biologic medications, which are delivered by injection of IV infusion, target specific parts of the immune system. There is a variety from which to choose, including:

• Adalimumab (Humira)
• Ustekinumab (Stelara)
• Secukinumab (Cosentyx)
• Infliximab (Remicade)
• Simponi Aria (Golimumab)
  

Dr. Friedman often prescribes systemic agents for scalp psoriasis because he finds them more effective than topical options for the scalp and because those with scalp psoriasis have a three-fold increased risk of developing psoriatic arthritis.

"And you're not going to treat arthritis with a topical. But I am quick to have a discussion with patients that when it comes to treatment, it's not one or the other. They can make a good decision based on all the information available," said Dr. Friedman.

A Quick Review

Scalp psoriasis can be an irritating condition that causes a buildup of skin cells on the scalp. These itchy patches can be bothersome, but topical, oral, and biological treatments can be used to treat your symptoms.

Treatment can differ for each person, so it's important to consult your dermatologist to figure out which treatment plan will be best for you.